Form PSI StateTribal PSI StateTribal PSI StateTribal

OMB No. xxxx-xxxx

Expiration Date: Month XX, 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 3 hours 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.

Garrett Lee Smith (GLS) National Outcomes Evaluation

State/Tribal Suicide Prevention Program

Prevention Strategies Inventory (PSI)

OUTREACH AND AWARENESS

Public Awareness Campaigns

Public Awareness Campaigns are organized systematic efforts using multiple communications media to make the general public or a particular target population aware of key messages about suicide prevention.

*Please note: campaigns that are specific to means restriction should be reported under “Means Restriction Awareness Campaigns.”

Examples of Public Awareness Campaigns are: the “Be Well to Do Well (BW2DW)” mental health awareness campaign; the “I Am Not a Bystander” campaign; the “How YOU Doin’” campaign; the “Suicide Shouldn't Be a Secret” campaign; the “Ask, Listen, Refer” campaign; and the “Don't Erase Your Future” campaign.

Outreach and Awareness Activities/Events

These are activities and events intended to promote awareness about suicide prevention and are not connected to a particular public awareness campaign.

*Please note: activities/events specific to means restriction should be reported under “Means Restriction Activities and Events.”

Examples of Outreach and Awareness Activities/Events are: a suicide prevention poster contest, an “Out of Darkness” walk, a booth at a health fair, suicide awareness day, and events held during National Red Ribbon Week.

Outreach and Awareness Products

These are products intended to promote awareness about suicide prevention. Their distribution is not limited to or connected to a particular public awareness campaign or to a particular activity/event.

*Please note: products specific to means restriction should be reported under “Means Restriction Products.”

Examples of Outreach and Awareness Products are: radio and TV Public Service Announcements; Website development or enhancement; newspaper articles; billboards; and awareness products such as stress balls, mood pens, T-shirts and bracelets.

GATEKEEPER TRAINING

School-Based Adult

School-based gatekeeper training programs are trainings designed to help school staff identify students at risk of suicide and to refer them for help. School adult gatekeepers may include any adult in the school (e.g., counselors, teachers, coaches, administrators or cafeteria staff and other school-based staff and volunteers) in a position to observe and interact with students. Example: ASIST training for teachers.

School-Based Peer

School-based peer gatekeeper training programs are trainings designed to help students identify peers at risk of suicide and refer them for help. These programs may be targeted to all students in middle school or high school or a particular grade. Some programs may also be targeted towards selected “peer helpers”, who are usually selected through a process (by self, peers, teachers, counselors, etc,). Examples of programs to be included here are: Signs of Suicide (SOS), Lifelines, natural helpers program etc.

Community Adult

Community adult gatekeeper training programs are intended to train adult community members to identify young people at risk of suicidal behaviors and to refer them to appropriate sources of help. This "gatekeeping" function can be undertaken by anyone who has significant contact with youth in the course of professional or volunteer activities. Examples of gatekeepers include coaches, clergy, police officers, health care professionals, emergency medical services personnel, hairdressers and barbers, nurses, primary care physicians and other traditional caregivers. Example: QPR training for police officers.

Community Peer

Peer gatekeeper training programs are intended to train youth to become “helpers” for other youth within their own peer groups. They are trained to identify peers at risk of suicidal behaviors and refer them to appropriate sources of help. Any youth may function as a peer gatekeeper - tribal youth council members, natural helpers or veterans. *Please note that if you are training youth in a school setting, select “School-based peer gatekeeper training”. If you are training youth in non-school settings, select “Community Peer Gatekeeper training”.

ASSESSMENT, CLINICAL, AND REFERRAL TRAINING

For Mental Health Professionals

This category refers to training mental health professionals on assessing, managing, and treating suicide risk and making appropriate referrals. Examples of these types of trainings are: Assessing and Managing Suicide Risk (AMSR) for mental health professionals and training clinicians in suicide assessment.

For Hotline Staff

This category refers to training hotline staff in suicide risk assessment and referral skills. These trainings are generally gatekeeper training, but must have the specific goal of training those who will be staffing a hotline or helpline.

LIFE SKILLS AND WELLNESS development

Lifeskills Development for Youth Curricula

Use of a curricula that aim to teach children and adolescents the social competencies and life skills needed to support positive social, emotional, and academic development. These life skills include communication, problem solving, depression and stress management, anger regulation, and goal setting.

For example, the American Indian Lifeskills Development Curriculum covers the following topics: building self-esteem; identifying feelings, emotions, and life stressors; developing effective communication and problem-solving skills; recognizing and eliminating self-destructive behavior; exploring reasons why people attempt suicide; identifying ways to help friends who are considering suicide; and planning for the future.

Cultural Activities

Activities that use a “culture as prevention” approach and are intended to strengthen the cultural identity of youth in order to provide them with a feeling of security, a sense of belonging and hope for the future.

Examples of activities that would fall under this category are: culture camps where youth learn about their traditions, history and languages; recreational activities such as canoe trips, maze and high rope; activities to teach youth traditional arts and crafts; youth drumming and dancing events; and community events such as ceremonies and feasts.

Wellness Activities

These activities include workshops, educational seminars, speaking events, and trainings that provide students with essential life skills and promote wellness. These activities intend to support positive social, emotional, spiritual, and academic development.

Examples of Life Skills and Wellness Activities are: workshops on stress management or healthy relationships; seminars on depression, anxiety, eating disorders and body image; tai chi; yoga; meditation; progressive muscle relaxation; and dance and movement.

SCREENING PROGRAMS

Early Identification Screening Programs involve the administration of a screening instrument or an online mental health screening tool to identify at-risk youth.

Examples of Screening Programs include: Depression Screening, ISP, other online screening tools.

HOTLINES, HELPLINES, TEXTLINes, and chatlines

Hotlines and Helplines

Developing, maintaining or supporting hotline or helpline services for the community.

For example, a grantee may use GLS funds to develop and maintain a hotline service for LGBT youth or a grantee can use funds to develop a local call center for the National Suicide Prevention Lifeline.

*Please note: training for hotline staff should be indicated under “Assessment and Referral Training for Hotline Staff.” Also, materials promoting the National Suicide Prevention Lifeline should be reported under “Outreach and Awareness Products.”

Textlines and Chatlines

Developing, maintaining, or supporting text or web-based chat support services for the community.

*Please note: training for text and chat staff should be indicated under “Assessment and Referral Training for Hotline Staff” and materials promoting the textline, chatline, or National Suicide Prevention Lifeline should be reported under “Outreach and Awareness Products.”

MEANS RESTRICTION

Means Restriction are efforts that aim to educate about the issue of lethal means restriction. Examples of efforts that would be reported under this category include: a campaign dedicated to reducing access to lethal means, and outreach and awareness events, activities and materials focused on issues related to access to lethal means.

Means Restriction Public Awareness Campaigns

A Means Public Awareness Campaign is an organized systematic effort through various communications media focused on creating awareness about access to lethal means among the general public or particular target populations. For example: the “Lock ‘Em Up” Prescription Drug Campaign.

Distribution of Gun Locks and Lock Boxes

This refers to distribution of gun locks, locks for gun cabinets and lockboxes which can store items such as medicines, ammunition & knives.

Means Restriction Activities and Events

Events or activities intended to promote awareness about access to lethal means but not connected to a particular public awareness campaign.

Means Restriction Products

Products intended to promote awareness about access to lethal means and not connected to a particular public awareness campaign.

Examples of these types of products are: radio and TV Public Service Announcements, Website development or enhancement, newspaper articles, brochures, billboards, and awareness products such as stress balls, mood pens, T-shirts, and bracelets.

Means Restriction Training

Training designed to teach behavioral health professionals to counsel the families of those at-risk for suicide in methods to reduce access to lethal means.

Lethal Means Counseling

Assessing the access an at-risk youth has to lethal means and counseling their family to restrict access to these lethal means while the youth is at-risk.

POLICIES, PROTOCOLS, AND INFRASTRUCTURE

These are policies and protocols utilized by a special team formed to respond to youth at risk or to crisis situations, and to involve various individuals, agencies and services, including mental health centers, hospitals, mobile crisis teams, police, parents/guardians, etc. Polices and protocols are formally written statements documenting the procedures to be followed. This strategy also includes infrastructure development related to the utilization of electronic health records to enhance suicide prevention efforts.

Policies and Protocols Related to Intervention

Policies and protocols related to intervention guide the actions of all agencies and personnel involved in ensuring that at-risk students receive coordinated, timely and effective assessment, referral, treatment, and follow-up support.

Policies and Protocols Related to Postvention

Policies and protocols related to postvention guide the actions of all agencies and staff involved in taking appropriate postvention steps to support family, friends, and other community members following a suicide, and to prevent cluster suicides.

Electronic Health Record Implementation and Utilization

The implementation or utilization of electronic health records to align with suicide prevention efforts, such as tracking follow up services or referrals, enhancing communications, or improving surveillance.

COALITIONS AND PARTNERSHIPS

The leading, support, or participating agencies, programs or organizations in suicide prevention or other prevention coalitions are examples of partnerships. This category also includes partnerships that result in coordinated services or activities.

Leading or Substantially Supporting a Suicide Prevention Coalition

The development of a means for cooperation and collaboration among persons, groups, or organizations to work together toward goals related to suicide prevention.

Leading or Substantially Supporting a Coalition That Is Closely Related to Youth Suicide Prevention

The development of a structured arrangement for cooperation and collaboration among persons, groups, or organizations, in order to work together toward goals related to youth prevention (e.g., youth violence, substance abuse) or the promotion of health and well-being.

Participating In Coalitions Related to Youth Prevention

Participation in or support of coalitions related to prevention efforts (e.g., youth violence, domestic violence, or substance abuse) or the promotion of mental health and well-being.

Partnerships with Agencies and Organizations

Efforts to build partnerships to facilitate timely, effective and coordinated suicide prevention and early identification. These partnerships will generally involve a memorandum of understanding or other formal agreement.

DIRECT SERVICES AND TRADITIONAL HEALING PRACTICES

Mental Health Related Services

Mental health–related services that are provided or supported by a grantee’s suicide prevention program. Examples of potential mental health related services are: Assessment services (e.g., a clinical assessment resulting from an early identification activity or referral); Counseling services; and Family Support services.

Postvention Services

Services that are provided or supported by a grantee’s suicide prevention program after a suicide attempt or a death by suicide, largely taking the form of support for the bereaved (i.e., family, friends, professionals, and peers). Examples of postvention services include: Family support services; Community support services; Group or individual support services; and Peer support groups.

Case Management Services

Case management services that are provided or supported by a grantee’s suicide prevention program. Services include assessing the needs of the at risk youth and his or her family, and arranging, coordinating, monitoring, evaluating, and advocating for a package of multiple services to meet the youth’s specific needs.

Crisis Response Services

Emergency services such as crisis response services or mobile response services provided or supported by a grantee’s suicide prevention program.

Traditional Healing Practices

This category refers to traditional healing practices grounded in Native history and culture which help individuals move towards a state of mental well-being. These may include practices such as sweat lodge ceremonies, talking circles in response to a crisis, spiritual ceremonies and other cultural practices that support healing and recovery.

Follow Up Services

This refers to efforts focused on ensuring that youth receive appropriate services following identification, such as follow up phone calls or reminders.

OTHER SUICIDE PREVENTION STRATEGIES

Prevention strategies that cannot be classified under the previously listed strategy types can go under “Other.” Items that are commonly reported in this strategy include: other trainings (e.g., cultural competence/SafeZone trainings), congressional testimony/advocacy, postvention activities or products, or work to make suicide prevention education part of a course curriculum or degree requirement.

OUTREACH AND AWARENESS

Public Awareness Campaigns

1. What is the name of the public awareness campaign?

2. Please describe the public awareness campaign. Include information such as goals, methods/elements and intended audiences.

3. Does this strategy target the general population (i.e., the entire community)?

• Yes [Go to Q. 6]

• No [Continue with Q.5]

4. If no, please indicate the populations targeted by the public awareness campaign. Select all that apply.

• Youth/Students

• Parents/Guardians

• Mental Health Professionals

• Child Welfare Staff

• University College/Faculty Staff

• Juvenile Justice Staff

• Primary Care Staff

• Education Staff

• Other, please specify: ____________________

5. Does your campaign place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

6. Please indicate which of the following elements are used in this public awareness campaign, and for each selected element, please provide a brief description.

• Print materials such as brochures, posters and flyers. Please describe: _______________

• Print media such as newspapers/magazines/newsletters. Please describe: ____________

• Billboards. Please describe: ____________________

• Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.)

• Please describe: ____________________

• Web site development/enhancement. Please describe: ____________________

• Social media (Facebook, Twitter, Instagram, etc.

• Radio. Please describe: ____________________

• TV. Please describe: ____________________

• DVD. Please describe: ____________________

• Events/activities. Please describe: ____________________

• Booth at health fair. Please describe: ____________________

• Other. Please describe: ____________________

Outreach and Awareness Activities and Events

1. What is the name of activity/event?

2. Type of activity/event

• Participation in a Health Fair (ex. Booth or table)

• Awareness walk (ex. Out of Darkness)

• Poster contest

• Awareness/informational presentation

• Other, please specify: ____________________

3. Please describe the activity or event. Explain how the activity or event relates to the goals of your suicide prevention program.

4. Does this strategy target the general population (i.e., the entire community)?

• Yes [Go to Q. 7]

• No [Continue with Q.6]

5. If no, please indicate the populations targeted by the activity or event. Select all that apply.

• Youth/Students

• Parents/Guardians

• Mental Health Professionals

• Child Welfare Staff

• University College/Faculty Staff

• Juvenile Justice Staff

• Primary Care Staff

• Education Staff

• Other, please specify: ____________________

6. Does this activity/event place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

Outreach and Awareness Products

1. What is the name of product?

2. Type of product

• Print materials such as brochures, posters and flyers

• Print media such as newspapers/magazines/newsletters

• Billboards

• Awareness products (such as stress balls, key chains, mood pens, T-shirts etc.)

• Mobile applications

• Web site development/enhancement

• Social media (Facebook, Twitter, Instagram, etc.)

• Radio

• TV

• DVD

• Other, please specify: ____________________

3. Please describe the product. Explain how this product relates to the goals of your suicide prevention program.

4. Does this strategy target the general population (i.e., the entire community)?

• Yes [Go to Q. 7]

• No [Continue with Q.6]

5. If no, please indicate the populations targeted by the activity or event. Select all that apply.

• Youth/Students

• Parents/Guardians

• Mental Health Professionals

• Child Welfare Staff

• University College/Faculty Staff

• Juvenile Justice Staff

• Primary Care Staff

• Education Staff

• Other, please specify: ____________________

6. Does this product place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

Gatekeeper Training

School-Based Adult Gatekeeper Training

1. What is the name of the training?

2. Please indicate the type of training:

• QPR (Question, Persuade, Refer)

• ASIST (Applied Suicide Intervention Skills Training)

• SafeTALK

• Lifelines

• Signs of Suicide (SOS)

• Other, please specify: ____________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Were the trainees members of the general population (i.e., the entire community)?

• Yes [Go to Q.6]

• No [Continue with Q.5]

4. If no, please indicate the types of trainees. Select all that apply.

• Teacher

• School Administrator

• Mental health clinician/counselor/ psychologist

• Social Worker/ Caseworker/Care coordinator

• Emergency/crisis care worker

• Administrative assistant/clerical support personnel

• Academic advisor

• Coach

• Cafeteria staff

• Other, please specify: ____________________

5. Does this training place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

6. Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees: how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc. If you are using a locally developed curriculum, please also describe the content of the curriculum.

7. How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? (Select all that apply)

• Youth information are entered into an electronic database; electronic alerts at specified follow up intervals

• Trainee responsible for tracking and monitoring follow-up

• Grant staff responsible for tracking and monitoring follow-up

• Care coordinator responsible for tracking and monitoring follow-up

• Other process, please describe __________________

8. What practices or protocols are in place to follow up with youth who do not receive a mental health service (or other support services) within three months of referral? (Select all that apply)

• Trainee follows up with youth to determine why services have not been received

• Trainee follows up with parent/guardian to determine why services have not been received

• Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow up

• Other process, please describe________________________________

School-Based Peer Gatekeeper Training

1. What is the name of training?

2. Please indicate the type of training:

• Yellow Ribbon

• Signs of Suicide (SOS)

• Youth Depression & Suicide: Let’s Talk

• Lifelines

• Sources of Strength

• QPR (Question, Persuade, Refer)

• Other, please specify: ____________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Were the trainees members of the general population (i.e., the entire community)?

• Yes [Go to Q.6]

• No [Continue with Q.5]

4. If no, please indicate the types of trainees. Select all that apply.

• All students

• Selected peer “natural helpers”

• Other, please specify: ____________________

5. Does this training place emphasis or focus on any of these priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

6. Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc. If you are using a locally developed curriculum, please also describe the content of the curriculum.

7. How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? (Select all that apply)

• Youth information are entered into an electronic database; electronic alerts at specified follow up intervals

• Trainee responsible for tracking and monitoring follow-up

• Grant staff responsible for tracking and monitoring follow-up

• Care coordinator responsible for tracking and monitoring follow-up

• Other process, please describe __________________

8. What practices or protocols are in place to follow up with youth who do not receive a mental health service (or other support services) within three months of referral? (Select all that apply)

• Trainee follows up with youth to determine why services have not been received

• Trainee follows up with parent/guardian to determine why services have not been received

• Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow up

• Other process, please describe________________________________

Community-Based Adult Gatekeeper Training

1. What is the name of training?

2. Please indicate the type of training:

• QPR (Question, Persuade, Refer)

• ASIST (Applied Suicide Intervention Skills Training)

• SafeTALK

• Lifelines

• Signs of Suicide (SOS)

• Other, please specify: ____________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Were the trainees members of the general population (i.e., the entire community)?

• Yes [Go to Q.6]

• No [Continue with Q.5]

4. If no, please indicate the types of trainees. Select all that apply.

• Parents/Guardians

• Mental Health Professionals

• Child Welfare Staff

• University College/Faculty Staff

• Juvenile Justice Staff

• Primary Care Staff

• Education Staff

• Other, please specify: ____________________

5. Does this training place emphasis or focus on any of these priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

6. Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc. If you are using a locally developed curriculum, please also describe the content of the curriculum.

7. How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? (Select all that apply)

• Youth information are entered into an electronic database; electronic alerts at specified follow up intervals

• Trainee responsible for tracking and monitoring follow-up

• Grant staff responsible for tracking and monitoring follow-up

• Care coordinator responsible for tracking and monitoring follow-up

• Other process, please describe __________________

8. What practices or protocols are in place to follow up with youth who do not receive a mental health service (or other support services) within three months of referral? (Select all that apply)

• Trainee follows up with youth to determine why services have not been received

• Trainee follows up with parent/guardian to determine why services have not been received

• Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow up

• Other process, please describe________________________________

Community-Based Peer Gatekeeper Training

1. What is the name of training?

2. Please indicate the type of training:

• Yellow Ribbon

• Signs of Suicide (SOS)

• Youth Depression & Suicide: Let’s Talk

• Lifelines

• Sources of Strength

• QPR (Question, Persuade, Refer)

• Other, please specify: ____________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Were the trainees members of the general population (i.e., the entire community)?

• Yes [Go to Q.6]

• No [Continue with Q.5]

4. If no, please describe the youth who are being targeted.

5. Does this training place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

6. Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc. If you are using a locally developed curriculum, please also describe the content of the curriculum.

7. How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? (Select all that apply)

• Youth information are entered into an electronic database; electronic alerts at specified follow up intervals

• Trainee responsible for tracking and monitoring follow-up

• Grant staff responsible for tracking and monitoring follow-up

• Care coordinator responsible for tracking and monitoring follow-up

• Other process, please describe __________________

8. What practices or protocols are in place to follow up with youth who do not receive a mental health service (or other support services) within three months of referral? (Select all that apply)

• Trainee follows up with youth to determine why services have not been received

• Trainee follows up with parent/guardian to determine why services have not been received

• Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow up

• Other process, please describe________________________________

assessment, Clinical, and referral Training for mental health professionals AND HOTLINE STAFF

Mental Health Professionals

1. What is the name of the training?

2. Please indicate the type of training:

• AMSR (Assessing and Managing Suicide Risk)

• RRSR (Recognizing and Responding to Suicide Risk)

• Cognitive Behavioral Theapy (CBT)
  Chronological Assessment of Suicide Events (CASE)

• Dialectical Behavior Therapy (DBT)

• Mental Health First Aid

• QPR for Nurses

• QPR for Physicians, Physician Assistants, Nurse Practitioners, and Others

• Other, please specify: ____________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Please indicate the types of trainees.

• Mental health clinician/counselor/ psychologist

• Social Worker/Caseworker / Care coordinator

• Other, please specify: ____________________

4. Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc. If you are using a locally developed curriculum, please also describe the content of the curriculum.

5. How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? (Select all that apply)

• Youth information are entered into an electronic database; electronic alerts at specified follow up intervals

• Trainee responsible for tracking and monitoring follow-up

• Grant staff responsible for tracking and monitoring follow-up

• Care coordinator responsible for tracking and monitoring follow-up

• Other process, please describe __________________

6. What practices or protocols are in place to follow up with youth who do not receive a mental health service (or other support services) within three months of referral? (Select all that apply)

• Trainee follows up with youth to determine why services have not been received

• Trainee follows up with parent/guardian to determine why services have not been received

• Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

• Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow up

• Other process, please describe________________________________

Hotline Staff

1. What is the name of the training?

2. Please indicate the type of training:

• QPR (Question, Persuade, Refer)

• ASIST (Applied Suicide Intervention Skills Training)

• SafeTALK

• Lifelines

• Signs of Suicide (SOS)

• Other, please specify: ____________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Please indicate the types of trainees.

• Mental health clinician/counselor/ psychologist

• Social Worker / Caseworker / Care coordinator

• Volunteers

• Other, please specify: ____________________

4. Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc. If you are using a locally developed curriculum, please also describe the content of the curriculum.

LIFE SKILLS AND WELLNESS DEVELOPMENT

Life Skills Development for Youth Curricula

1. What is the name of the curriculum?

2. Type of curriculum.

• American Indian Life Skills Development Curriculum

• Gathering Of Native Americans

• Other, please specify: ____________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Please describe the youth who are being targeted (age group, demographics etc.).

4. Does this life skills development strategy place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

5. Please describe the curriculum. Include information such as: why this particular curriculum type has been selected; how the curriculum has been adapted to meet the needs of this group; strategies for recruiting participants, etc. If you are using a locally developed curriculum, please also describe the content of the curriculum.

Cultural Activities

1. What is the name of the activity?

2. Type of activity.

• Culture camp

• Canoe trips

• Maze

• High Rope

• Traditional arts and crafts

• Drumming event

• Dancing event

• Ceremonies

• Other, please specify: ____________________

3. Please describe the activity.

4. Please describe the youth who are being targeted (age group, demographics etc.).

5. Does this cultural activity place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

Wellness Activities

1. What is the name of the activity?

2. Please describe the activity (include its purpose and how it relates to suicide prevention efforts).

3. Does this wellness activity place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

SCREENING PROGRAMS

1. What is the name of the screening tool?

2. Please indicate the type of screening tool:

• Patient Health Questionnaire (PHQ-9)

• Columbia Suicide Severity Rating Scale (CSSR-S)

• Behavioral Health Screen (BHS)

• Ask Suicide Screening Questions (asQ)

• Beck Depression Inventory (BDI)

• Suicide Behaviors Questionnaire (SBQ-R)

• Locally Developed Screening Tool

• Other, please specify: ____________________

3. Please describe the screening program.

4. Please indicate the settings targeted by the screening program. Select all that apply.

• School

• Child Welfare

• Juvenile Justice

• Physical Health

• Mental Health Agency

• Emergency Room

• Other, please specify: ____________________

5. What procedures or processes are in place to ensure that youth, identified as at-risk through this screening tool receive follow-up services within three months of referral? (Select all that apply)

• Screener follows up with youth to determine if services have been received

• Screener follows up with parent/guardian of youth to determine if services have been received

• Screener follows up with referral to determine if services have been received

• Youth are flagged in an electronic database and an alert is provided at weekly intervals for follow-up

• Other process, please describe: ____________________

6. How do you monitor or track youth after referral to ensure follow up services (mental health or other support services) are received? (Select all that apply)

• Youth information are entered into an electronic database; electronic records database alert at specified intervals

• Screener responsible for tracking and monitoring follow up

• Care coordinator responsible for tracking/monitoring follow up

• Other process, please describe: ____________________

7. What practices or protocols are in place to follow-up with youth who do not receive a mental health service (or other support service) within three months of referral? (Select all that apply)

• Screener follows up with youth to determine why services have not been received

• Screener follows up with parent/guardian to determine why services have not been received

• Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow-up

• Other process, please describe: ____________________

HOTLINES AND HELPLINES

Hotlines and Helplines

1. What is the name of the hotline/helpline?

2. Please describe the hotline/helpline. Include information such as whether it is locally developed or support of the NSPL, hours of function, whether it is open to the entire community etc.

3. Please indicate the populations targeted by the crisis hotline (geographic scope, demographics etc,).

Textlines and Chatlines

1. What is the name of the text/chatline?

2. Please describe the textline/chatline. Include information such as: whether it is locally developed or supported by the National Suicide Prevention Lifeline; its hours of operation; whether it is available to the entire community, etc.

3. Please indicate the populations targeted by the textline/chatline (geographic scope, demographics, etc.)

Means Restriction

Means Restriction Public Awareness Campaign

1. What is the name of the means restriction public awareness campaign?

2. Please describe the means restriction public awareness campaign–its goals, methods/elements and intended audiences.

3. Does this strategy target the general population (i.e. the entire community)?

• Yes [Go to Q.6]

• No [Continue to Q.5]

4. If no, please indicate the populations targeted by the means restriction public awareness campaign.

• Youth/Students

• Parents/Guardians

• Mental Health Professionals

• Child Welfare Staff

• University College/Faculty Staff

• Juvenile Justice Staff

• Primary Care Staff

• Education Staff

• Other, please specify: ____________________

5. Does this means restriction awareness campaign place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

6. Please indicate which of the following elements are used in this means restriction public awareness campaign, and for each selected element, please provide a brief description.

• Print materials such as brochures, posters and flyers. Please describe: _______________

• Print media such as newspapers/magazines/newsletters. Please describe: ____________

• Billboards. Please describe: ____________________

• Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.) Please describe: ____________________

• Website development/enhancement. Please describe: ____________________

• Social media (Facebook, Twitter, Instagram, etc.)

• Radio. Please describe: ____________________

• TV. Please describe: ____________________

• DVD. Please describe: ____________________

• Events/activities. Please describe: ____________________

• Booth at health fair. Please describe: ____________________

• Other, please describe: ____________________

Distribution of gun locks and lock boxes

1. What is the name of the distribution activity/event?

2. Please describe the distribution activity or event.

3. Does this strategy target the general population (i.e. the entire community)?

• Yes [Go to Q. 6]

• No [Continue to Q.5]

4. If no, please indicate the populations targeted by the distribution activity/event.

• Youth/Students

• Parents/Guardians

• Mental Health Professionals

• Child Welfare Staff

• University College/Faculty Staff

• Juvenile Justice Staff

• Primary Care Staff

• Education Staff

• Other, please specify: ____________________

5. Does this gun lock/lock box distribution place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

Means Restriction Activities and Events

1. What is the name of the means restriction activity/event?

2. Type of means restriction activity/event

• Participation in a Health Fair (ex. Booth or table)

• Poster contest

• Awareness/informational presentation

• Other, please specify: ____________________

3. Please describe the means restriction activity or event. Explain how the activity or event relates to the goals of your suicide prevention program.

4. Does this strategy target the general population (i.e. the entire community)?

• Yes [Go to Q.7]

• No [Continue to Q.6]

5. If no, please indicate the populations targeted by the means restriction activity or event. Select all that apply.

• Youth/Students

• Parents/Guardians

• Mental Health Professionals

• Child Welfare Staff

• University College/Faculty Staff

• Juvenile Justice Staff

• Primary Care Staff

• Education Staff

• Other, please specify: ____________________

6. Does this means restriction activity or event place emphasis or focus on any of these current priority populations? Select all that apply

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

Mean Restriction Products

1. What is the name of the means restriction product?

2. Type of means restriction product

• Print materials such as brochures, posters and flyers

• Print media such as newspapers/magazines/newsletters

• Billboards

• Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.)

• Mobile applications

• Web site development/enhancement

• Social media (Facebook, Twitter, Instagram, etc.)

• Radio

• TV

• DVD

• Other, please specify: ____________________

3. Please describe the means restriction product. Explain how this product relates to the goals of your suicide prevention program.

4. Does this strategy target the general population (i.e. the entire community)?

• Yes [Go to Q.7]

• No [Continue to Q.6]

5. If no, please indicate the populations targeted by the means restriction product. Select all that apply.

• Youth/Students

• Parents/Guardians

• Mental Health Professionals

• Child Welfare Staff

• University College/Faculty Staff

• Juvenile Justice Staff

• Primary Care Staff

• Education Staff

• Other, please specify: ____________________

6. Does this means restriction product place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

Means Restriction Training

1. What is the name of the training?

2. Please indicate the type of training:

• CALM (Counseling on Access to Lethal Means)

• Other, please specify: ____________________

2a. [IF OTHER] Is this a locally developed training?

• Yes

• No

3. Please describe the training. If you are using a standard curriculum, you need not describe the content of the curriculum. . If you are using a locally developed curriculum, please also describe the content of the curriculum. .Provide description such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; strategies for recruiting participants, etc.

4. Please indicate the types of trainees:

• Mental Health clinician/counselor/psychologist

• Social Worker/Caseworker/Care coordinator

• Other, please specify: ____________________

Lethal Means Counseling

1. Name of service: ______________

2. Please provide a brief description of the service:

POLICIES, PROTOCOLS, AND INFRASTRUCTURE

Policies and protocols related to intervention

1. What is the name of the policy/protocol?

2. Please describe the purpose of this policy/protocol? Who is included/involved in the implementation (staff/agencies)? How will this policy/protocol be used and communicated?

Policies and protocols related to Postvention

1. What is the name of the policy/protocol?

2. Please describe the purpose of this policy/protocol? Who is included/involved in the implementation (staff/agencies)? How will this policy/protocol be used and communicated?

Electronic health record implementation and/or utilization

1. Please describe how electronic health records are used to support suicide prevention efforts. Who is included/involved in implementation? In what setting is the electronic health record utilized?

2. In which of the following ways is the electronic health record used to enhance grant activities?

• Suicide screening and risk assessment

• Monitoring progress and follow up of youth after identification

• Communication between multiple providers

• Creating and sharing safety plans with youth and/or families

• Tracking scheduled appointments

• Tracking suicide attempts or deaths

• Other, please specify:

COALITIONS AND PARTNERSHIPS

Leading or Substantially Supporting a Suicide Prevention Coalition

1. What is the name of the coalition?

2. Please provide a brief description of the coalition (what types of agencies participate in the coalition? what are the goals of the coalition? what are its major achievements and how frequently do the members meet? what are strategies for sustaining the coalition, etc.).

Leading or substantially supporting a Coalition that is closely related to youth suicide prevention

1. What is the name of the coalition?

2. Please provide a brief description of the coalition.(what types of agencies participate in the coalition; what are the goals of the coalition; what are its major achievements; and how frequently do the members meet; what are strategies for sustaining the coalition, etc.)

Participation in Coalitions Related to Youth Prevention

1. What is the name of the coalition?

2. Please provide a brief description of the coalition. Include information such as: how does your participation in this coalition advance your suicide prevention efforts; what types of agencies participate in the coalition; what are the goals of the coalition; what are its major achievements; and how frequently do the members meet, etc.

Partnerships with Agencies and Organizations

1. Name of partnership strategy: ____________________

2. Please provide a brief description of your efforts to build partnerships with youth-serving agencies and organizations. These can include on-campus and off-campus partnerships.

DIRECT SERVICES AND TRADITIONAL HEALING PRACTICES

Mental Health Related Services

1. Name of service: ____________________

2. Type of service

• Assessment services (e.g., a clinical assessment resulting from an early identification activity or referral)

• Counseling services

• Family support services

• Other, please specify: ____________________

3. Please provide a brief description of the service:

Postvention Services

1. Name of service: ____________________

2. Please provide a description of the service:

Case Management Services

1. Name of service: ____________________

2. Please provide a brief description of the service:

Crisis response services

1. Name of service: ____________________

2. Please provide a brief description of the service:

Traditional Healing Practices

1. Name of service:

2. Please provide a brief description of the practice:

Follow up services

1. Name of service:

2. Please provide a brief description of the service:

3. What strategies do you use to follow up with youth after identification?

• Phone call

• Text message

• Letter

• Email

• Home Visit

• Other, please specify:

4. When is this service utilized?

• After identification by trained gatekeepers

• After identification by screening

• After Emergency Department discharge

• Other, please specify:

5. Please indicate the settings where follow up services are utilized. Select all that apply.

• School

• Child Welfare

• Juvenile Justice

• Physical Health

• Mental Health Agency

• Emergency Room

• Other, please specify: ____________

OTHER SUICIDE PREVENTION STRATEGIES

1. Name of suicide prevention strategy:

2. Type of suicide prevention strategy

• Inclusion of suicide prevention content into curriculum / course

• Congressional Testimony or advocacy work

• Cultural sensitivity training. Describe group: ____________________

• Postvention Training. Describe: ____________________

• Other training, please specify: ____________________

• Other, please specify: ____________________

3. Please provide a brief description of this suicide prevention strategy. Include information such as: type of strategy, target populations, etc.

4. Does this strategy place emphasis or focus on any of these current priority populations? Select all that apply.

• American Indian/Alaska Native

• Survivors of suicide

• Individuals who engage in nonsuicidal self-injury

• Suicide attempters

• Individuals with mental and/or substance abuse disorders

• Lesbian, gay, bisexual, and transgender (LGBT) populations

• Veterans, active military, or military families

• Hispanic or Latino population

• Transition Age Youth (aged 18-24)

• [If selected] Are youth connected to school or related systems?

• Yes

• No

• No

• Other, please specify: ____________________

BUDGET

How much of your GLS budget, including any matching funds, have you spent to date? Specify dollar amount: ____________________

Please estimate the percentage of your total budget expended to date on the following prevention strategies.

[ONLY MAJOR STRATEGY (BOLD CAPS) ARE REQUIRED]

OUTREACH AND AWARENESS ___%

Public Awareness Campaigns ___%

Outreach and Awareness Activities and Events ___%

Outreach and Awareness Products ___%

GATEKEEPER TRAINING ___%

School-Based Adult Gatekeeper Training ___%

School-Based Peer Gatekeeper Training ___%

Community-Based Adult Gatekeeper Training ___%

Community-Based Peer Gatekeeper Training ___%

ASSESSMENT AND REFERRAL TRAINING ___%

For Mental Health Professionals ___%

For Hotline Staff ___%

LIFE SKILLS AND WELLNESS DEVELOPMENT ___%

Life Skills Development For Youth Curricula ___%

Wellness Activities ___%

Cultural Activities ___%

SCREENING PROGRAMS ___%

HOTLINES, HELPLINES, TEXTLINES, AND CHATLINES ___%

Hotlines and Helplines ___%

Textlines and Chatline ___%

MEANS RESTRICTION ___%

Public Awareness Campaigns ___%

Distribution Of Gun Locks and Lock Boxes ___%

Means Restriction Events ___%

Means Restriction Products ___%

Means Restriction Training ___%

Lethal Means Counseling ___%

POLICIES, PROTOCOLS, AND INFRASTRUCTURE ___%

Related to Intervention ___%

Related to Postvention ___%

Electronic Health Record Implementation/Utilization ___%

COALITIONS AND PARTNERSHIPS ___%

Leading or Substantially Supporting A Suicide Prevention Coalition ___%

Leading or Substantially Supporting A Coalition That Is Closely Related To Youth Suicide Prevention ___%

Participating In Coalitions Related to Youth Prevention ___%

Partnerships With Agencies and Organizations ___%

DIRECT SERVICES AND TRADITIONAL HEALING PRACTICES ___%

Mental-Health Related Services ___%

Postvention Services ___%

Case Management Services ___%

Crisis Response Services ___%

Traditional Healing Practices ___%

Follow up Services ___%

OTHER SUICIDE PREVENTION STRATEGY ___%

QXXYYY

State/Tribal Prevention Strategies Inventory (PSI)
12/2015 1