Form Provider Trainee I Provider Trainee I Provider Trainee Instruments

Attachment E-1: TUP-S Baseline (RCT) State Tribal

OMB No. XXXX-XXXX
Expiration Date:
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 XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 20 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.

Garrett Lee Smith (GLS) National Outcomes Evaluation
State/Tribal Suicide Prevention Program
Training Utilization and Preservation Survey (TUP-S) and Verbal Consent Script
Baseline Version (RCT)
Hello, my name is [INSERT INTERVIEWER NAME], and I’m calling to speak with you about the training that you are
planning to attend on [INSERT TRAINING DATE]. Is now a good time for you to talk?
IF NO: Is there a better time to call back?
IF YES: Great! As I said, my name is [INSERT INTERVIEWER NAME], and I work for ICF International, a company that has
been contracted by SAMHSA (which stands for the Substance Abuse and Mental Health Services Administration) to conduct
the National Outcomes Evaluation of GLS suicide prevention programs across the country. As part of this evaluation, we are
interviewing a random sample of people who have attended suicide prevention trainings sponsored by GLS State and
Tribal grantees. We hope to learn more about any expectations you have for the trainings and how you anticipate using
what you will learn.
You have registered to participate in a training called [INSERT TRAINING NAME], as part of the State/Tribal component
of the GLS Youth Suicide Prevention and Early Intervention Program on [DATE OF TRAINING]. When you registered for
the training, you consented to be contacted for four surveys that will be administered to you over the course of 1 year. We
are contacting you now to administer the first survey. This survey asks questions about your expectations of the training,
what you plan to do with what you learn from the training, and about your background. Findings from this survey will help
inform SAMHSA about suicide prevention activities.
The survey will take approximately 20 minutes to complete and you will receive $10 for your participation. If you are
interested, I will give you some more information and request your verbal consent.
Before I ask you whether you agree to be interviewed, there are a few more things that you should know.
Rights Regarding Participation: Your input is important; however, your participation in this survey is completely voluntary.
There are no penalties or consequences for not participating. You can choose to stop the interview at any time, or not
answer a question for whatever reason. If you stop the interview, at your request, we will destroy the survey. You may ask
any questions that you have before, during, or after you complete the survey. May I continue?
Privacy: Your answers are private and will not be linked to your name. Your name will never appear in any report that
summarizes the findings of the National Outcomes Evaluation. All findings will be reported in aggregate; that is, they will
be combined with responses from other individuals.
Additional Protection: In addition, to protect the information that you give us, we have applied for a Certificate of
Confidentiality from the U.S. Department of Health and Human Services (HHS). The Certificate of Confidentiality will
protect the members of the research staff from being forced, even under a subpoena, to release any information in which
you are identified. Exceptions to the Certificate of Confidentiality are information on child abuse and neglect, or
information regarding imminent danger to yourself or others, which we will report to the appropriate local and State
agency. Additionally, HHS may see your information if we are audited. Finally, the Certificate of Confidentiality does not
imply the endorsement or the disapproval of the HHS.
Risks: Completing this interview poses few, if any, risks to you. Some questions may make you feel uncomfortable. You can
choose not to answer any question for any reason. You may choose to stop the survey at any time, or not answer a question

for whatever reason. You will not be penalized for stopping. You can contact the principal investigator of the project at
any time. If you stop the interview, at your request, we will destroy your survey.
Benefits: Your participation will not result in any direct benefits to you. However, your input will contribute to a national
effort to prevent suicide.
I am not an expert in the subject matter, and I do not work for the people who provided the training, so please feel free to
respond honestly. There are no wrong answers. We’re just interested in your thoughts and opinions.
Compensation: You will receive a $10 Amazon gift code or money order for participating in this survey.
Contact Information: If you have any concerns about completing this survey or have any questions about the study, please
contact Christine Walrath, principal investigator, at (212) 941-5555 or [email protected].
Do you have any questions?
Do you agree to participate in this interview?



Yes
No

IF YES, continue.
Can you confirm that you are over 18 years of age?



Yes
No

IF YES, continue.
Thank you in advance for your willingness to participate. This call may be recorded and/or monitored for quality
assurance purposes.
To begin, I’m going to ask you some questions about the knowledge you gained at the training.
1. You are registered to participate in a training regarding suicide prevention on [INSERT TRAINING DATE], correct?



Yes
No

We want to learn about know how you think the [INSERT TRAINING NAME] will help in your work, home, or community.
[Interviewer Instructions: If asked, the setting of interest is the one where they are most likely to use their training.]
Part 1. I’d like to start by asking some questions about what you are expecting to experience from the training experience
and how you think you will use what you learn at the training
2. Do you expect to use your training to do any of the following? (Select all that

Yes
apply.)

No
a. Screen youths for suicidal behaviors (i.e., using a screening tool)

I have not used my
b. Formally publicize information about suicide prevention or mental health
training
resources

NOT APPLICABLE
c. Have informal conversations about suicide and suicide prevention with youths
and others

DK
d. Identify youths who might be at risk for suicide

REFUSED
e. Provide direct services to youths at risk for suicide and/or their families
f. Train other staff members to intervene with youths at risk for suicide
g. Make referrals to mental health services for at-risk youths
h. Work with adult at-risk populations
State/Tribal TUP-S Baseline (RCT)
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3. In the last 12 months, how many trainings or presentations about suicide or
suicide prevention have you attended? [Please do not include booster or
refreshers of the training in which you consented to participate in this survey.]








1–5
6–10
11–20
None
DK
REFUSED






Yes
No
DK
REFUSED






Yes
No
DK
REFUSED








Very high
High
Low
Very low
DK
REFUSED

7. How appropriate do you think it is to ask someone who may be at risk for
suicide about suicide?








Very appropriate
Appropriate
Somewhat appropriate
Not at all appropriate
DK
REFUSED

8. What is the likelihood you will ask someone who appears to be at risk if they
are thinking of suicide?








Very likely
Likely
Somewhat likely
Not at all likely
DK
REFUSED

3.1 [If more than one] Which training(s) about suicide or suicide prevention have
you received?
4. [If more than one training] Have you received any booster training in suicide
prevention in the last 12 months? [We mean booster or refresher sessions
directly related to the training in which you consented to participate in this
survey.]
4.1 [IF YES] Which booster training(s) have you received?

5. Have you received any training to support your ability to track or monitor youth
you identified at-risk?

Part 2. The following questions are about your knowledge about suicide prevention
6. For each of the following statements, please tell me how you would rate your
knowledge:
a. Facts concerning suicide prevention.
b. Warning signs of suicide.
c. How to ask someone about suicide.
d. Persuading someone to get help.
e. How to get help for someone.
f. Information about resources for help with suicide.

State/Tribal TUP-S Baseline (RCT)
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4

9. Please read each statement and use the rating scale to indicate the degree to
which you agree or disagree with it. It is important that you answer all
statements according to your beliefs and not what you think others may want
you to believe.
a. If someone I knew was showing signs of suicide, I would directly raise the
question of suicide with them.
b. 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.
c. If someone told me they were thinking of suicide, I would intervene.
d. I feel confident in my ability to help a suicidal person.
e. I don’t think I can prevent someone from suicide.
f. I don’t feel competent to help a person at risk of suicide.
Part 3. The next set of questions ask about your experiences with youths at risk for suicide.









Strongly agree
Agree
Disagree
Strongly disagree
NOT APPLICABLE
DK
REFUSED

10. In the last 12 months, have you identified youths you thought might be at risk
for suicide?
Twelve months ago was [today’s date – 12 months].






Yes
No
DK
REFUSED

10.1 [IF YES] About how many youths have you identified in the last 12
months?






Provide number
None
DK
REFUSED

10.2 [IF YES] About how many youths have you identified in the last 6
months?






Provide number
None
DK
REFUSED

10.3 [IF YES] About how many youths have you identified in the last 3
months?






Provide number
None
DK
REFUSED

[IF identifications are greater than one] The following questions refer to the most recent occasion when you identified a
youth at risk for suicide.
11. Thinking about the youth you identified most recently, did you ask the youth
whether she/he was considering suicide?






Yes
No
DK
REFUSED

12. Thinking about the youth you identified most recently, in which of the following
settings was that youth identified?






School
Child welfare agency
Juvenile justice agency
Law enforcement
agency
Physical health agency
(e.g., primary care,
pediatrician’s office)

12.1 [IF SOME OTHER PLACE] And what was the other place?



State/Tribal TUP-S Baseline (RCT)
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5




Emergency response
unit or emergency
room
Mental health agency
Community-based
organization,
recreation, or after
school activity
Home
Digital medium (e.g.,
Facebook or text
message)
Some other place
(SPECIFY)
DK
REFUSED

13. Thinking about the youth you identified most recently, did you refer the youth to
get further assistance or support?






Yes
No
DK
REFUSED

13.1 [IF YES] About how many youths that you have identified did you refer for
further assistance or support?






Provide number
None
DK
REFUSED

13.2 [IF YES] Thinking about the youth you identified most recently, to what
services, resources, or individuals did you refer the youth?




Mental health agency
Psychiatric
hospital/unit
Emergency room
Substance abuse
treatment center
School counselor
Private mental health
practice
Mobile crisis unit
Did not refer to
another place because
you provided services
directly to youth
Some other place
(SPECIFY)
DK
REFUSED











13.3 And what type of place is this?












State/Tribal TUP-S Baseline (RCT)
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14. Thinking about the youth you identified most recently, did you notify that
referral resource about the referral?






Yes
No
DK
REFUSED

15. Thinking about the youth you identified most recently, did you take the youth to
the service or resources you were recommending?






Yes
No
DK
REFUSED

16. Thinking about the youth you identified most recently, did you reach out to the
youth, his or her family, or service provider to ensure that the youth had access
to mental health services or other support services?






Yes
No
DK
REFUSED

17. Thinking about the youth you identified most recently, did you receive a formal
confirmation that the youth received the service?






Yes
No
DK
REFUSED

18. Did the youth receive the services to which he/she was referred?






Yes
No
DK
REFUSED





Less than 1 day
Less than 1 week
Between 1 and 2
weeks
More than 2 weeks
and up to 4 weeks
More than 1 month
DK
REFUSED

18.1 [IF DK] Why don’t you know if the youth received services?

[Skip if DK whether youth received service.]
19. Thinking about this same youth, about how many days did it take from the time
you made the referral to when the youth received his or her first service?





[Skip if DK whether youth received service]



20. Again, thinking about this same youth, what was the first service he or she
received? Was it one of the following?



20.1 [IF SOME OTHER SERVICE] And could you please describe this other service
to me?





State/Tribal TUP-S Baseline (RCT)
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7

Mental health
assessment
Substance use
assessment
Mental health
counseling
Substance abuse
counseling
Inpatient or residential
psychological services




Psychiatric services or
medication
management without
therapy
Some other service I
have not mentioned
DK
REFUSED






Yes
No
DK
REFUSED

[Skip if DK whether youth received service.]



22. What additional mental health services did he or she receive?



Mental health
assessment
Substance use
assessment
Mental health
counseling
Substance abuse
counseling
Inpatient services or
residential
psychological services
Psychiatric services or
medication
management without
therapy
Some other service I
have not mentioned
DK
REFUSED





[Skip if DK whether youth received service.]
21. Did he or she receive any additional mental health services since that first
appointment?

22.1 [IF SOME OTHER SERVICE] Could you please describe this other service to
me?











Part 4. The next set of questions is about your personal background and experience with individuals in crisis.
23. Please indicate the primary setting in which you interact with youth.

Education (K-12)









State/Tribal TUP-S Baseline (RCT)
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Substance abuse
Juvenile
justice/Probation
Emergency response
Higher education
(college/university)
Tribal services/Tribal
government
Child welfare
Mental health
Primary health care
(other than mental
health)




24. Within that setting, please select the ONE ROLE that you feel best describes you.

Other community
settings
DK
REFUSED

If education (K–12)

Teacher

School administrator

Mental health
clinician/Counselor/

Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis care
worker

Program evaluator

Administrative
assistant/Clerical
support personnel

Academic advisor

Tutor
If substance abuse

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis care
worker

Program evaluator

Administrative
assistant/Clerical
support personnel
If juvenile justice/probation

Program/System
administrator

Probation officer

Social worker/Case
worker/Care
coordinator

Detention facility
guard

State/Tribal TUP-S Baseline (RCT)
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


Program evaluator
Administrative
assistant/Clerical
support personnel

If emergency response

Police officer or other
law enforcement staff

Program/System
administrator

Emergency medical
technician

Fire fighter

Program evaluator

Administrative
assistant/Clerical
support personnel
If higher education
(college/university)

Faculty/Professor/
Researcher

Administrator (e.g.,
dean’s office, vice
president, provost)

Residential life staff

Mental health
Clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis care
worker

Program evaluator

Administrative
assistant/Clerical
support personnel

Student
If tribal services/tribal
government

Traditional tribal
healer

Tribal elder

Elected tribal official

Program/System
administrator
State/Tribal TUP-S Baseline (RCT)
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10










Mental health
clinician/Counselor/
Psychologist
Social worker/Case
worker/Care
coordinator
Community outreach
worker
Emergency/Crisis care
worker
Program evaluator
Administrative
assistant/Clerical
support personnel

If child welfare

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis care
worker

Program evaluator

Administrative
assistant/Clerical
support personnel
If mental health

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis care
worker

Program evaluator

Administrative
assistant/Clerical
support personnel

State/Tribal TUP-S Baseline (RCT)
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11

If primary health care (other
than mental health)

Program/system
administrator

Physician

Nurse

Nursing
assistant/Health
technician

Program evaluator

Administrative
assistant/Clerical
support personnel
If other community settings

Parent or
foster/Resource parent

Other caregiver

Relative

Youth mentor

Volunteer (i.e., big
brother/big sister,
CASA)

Youth advocate

Clergy/religious
educator

OTHER (please
specify):

DK

REFUSED

25. [Recall setting where trainee interacts with youths] Are there clear, widely used
steps that should be followed after a youth is identified as at risk for suicide?






Yes
No
DK
REFUSED

26. [Recall setting where trainee interacts with youths] Are there clear, widely used
steps that should be followed after a referral is made to make sure the youth
received the services?






Yes
No
DK
REFUSED

State/Tribal TUP-S Baseline (RCT)
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12

27. Is there an established, shared protocol regarding steps that should be followed
after identification?






Yes
No
DK
REFUSED

28. On a typical day, about how much time do you spend interacting or talking
directly with youths?












0–15 minutes
16–30 minutes
31 minutes–1 hour
1–2 hours
Up to 3 hours
Up to 4 hours
Up to 5 hours
More than 5 hours
DK
REFUSED

29. What is the nature of your interactions or work with youths?









Teaching
Counseling/Advising
Providing mental
health services
Case management
(e.g., child welfare,
juvenile justice)
Volunteer/Mentoring
(e.g. big brother/big
sister, volunteer)
No formal work;
interactions with youth
are intermittent within
the community setting
Church/spiritual
advisor
Neighbor
DK
REFUSED

30. Please consider your relationships with youths in responding to the following
items:
a. Youths talk to me about their thoughts and feelings.
b. Youths come to me for advice and assistance when they are troubled.
c. Youths turn to me when they are concerned about another
peer.









Never
Seldom
Sometimes
Nearly always
Always
DK
REFUSED

31. Do you know anyone who has died by suicide? [If no baseline, i.e., core]






Yes
No
DK
REFUSED









State/Tribal TUP-S Baseline (RCT)
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13

31.1 [IF YES] What was your relationship to this person or these persons? (Select
all that apply)












Family
Friend
Coworker
Patient
Neighbor
Acquaintance
Youth
Other (please specify)
DK
REFUSED

32. What is your gender?










Female
Male
Transmale
Transfemale
Gender nonconforming
Other
DK
REFUSED

33. What is your age?

Age: ______

DK

REFUSED

34. Are you Hispanic or Latino






Yes
No
DK
REFUSED

34.1 [IF YES] Which group represents you? (Select all that apply.)



Mexican, Mexican
American, or Chicano
Puerto Rican
Cuban
Dominican
Central American
South American
Other Hispanic or
Latino
DK
REFUSED









35. What is your race? (Select all that apply.)






State/Tribal TUP-S Baseline (RCT)
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14

American Indian or
Alaska Native
Asian
Black or African
American
Native Hawaiian or
other Pacific Islander






White
Other
DK
REFUSED




Yes
No

Wrap-up: This is the last set of questions.
36. I would like to offer you one of two ways to receive your $10 honorarium. I can
either give it to you now over the phone as an Amazon.com gift code, or I can
confirm your address and send it as a money order. Which would you prefer?
(If money order is selected, interviewer will confirm mailing address with the information we
have on file.)
37. Are you willing to be contacted again in 3 months to answer some additional
follow-up questions after your training about how you’ve used the information
and skills you learned?

Thank you very much for your time today. Your information will be very valuable to SAMHSA in its efforts to reduce
suicide among youths. If you have any questions or concerns about this survey,
please contact Christine Walrath, ICF, at (646) 695-8154.

State/Tribal TUP-S Baseline (RCT)
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Attachment E-2: TUP-S 3 Month (Core-RCT) State Tribal

OMB No. XXXX-XXXX
Expiration Date: Date
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 XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 30 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.

Garrett Lee Smith (GLS) National Outcomes Evaluation
State/Tribal Suicide Prevention Program
Training Utilization and Preservation Survey (TUP-S) and Verbal Consent Script
3-Month Version (Core and RCT)
Hello, my name is [INSERT INTERVIEWER NAME], and I’m calling to speak with you about the training that you attended
on [INSERT TRAINING DATE]. Is now a good time for you to talk?
IF NO: Is there a better time to call back?
IF YES: Great! As I said, my name is [INSERT INTERVIEWER NAME], and I work for ICF International, a company that has
been contracted by SAMHSA (which stands for the Substance Abuse and Mental Health Services Administration) to conduct
the National Outcomes Evaluation of GLS suicide prevention programs across the country. As part of this evaluation, we are
interviewing a random sample of people who have attended suicide prevention trainings sponsored by GLS State and
Tribal grantees. We hope to learn more about the trainings, how you have used what you learned, and the impact of the
training on you and your interactions with your peers.
On [DATE OF TRAINING], you participated in a training called [INSERT TRAINING NAME] as part of the State/Tribal
component of the GLS Youth Suicide Prevention and Early Intervention Program. Before the training, you consented to
be contacted for a follow-up survey. We are contacting you now to administer the survey. This survey asks questions about
the training, what you plan to do with what you learned during the training, and your satisfaction with the training. Findings
from this survey will help inform SAMHSA about GLS suicide prevention activities.
The survey will take approximately 30 minutes to complete and you will receive $10 for your participation. If you are
interested, I will give you some more information and request your verbal consent.
Before I ask you whether you agree to be interviewed, there are a few more things that you should know.
Rights Regarding Participation: Your input is important; however, your participation in this survey is completely voluntary.
There are no penalties or consequences for not participating. You can choose to stop the interview at any time, or not
answer a question for whatever reason. If you stop the interview, at your request, we will destroy the survey. You may ask
any questions that you have before, during, or after you complete the survey. May I continue?
Privacy: Your answers are private and will not be linked to your name. Your name will never appear in any report that
summarizes the findings of the National Outcomes Evaluation. All findings will be reported in aggregate; that is, they will
be combined with responses from other individuals.
Additional Protection: In addition, to protect the information that you give us, we have applied for a Certificate of
Confidentiality from the U.S. Department of Health and Human Services (HHS). The Certificate of Confidentiality will
protect the members of the research staff from being forced, even under a subpoena, to release any information in which
you are identified. Exceptions to the Certificate of Confidentiality are information on child abuse and neglect, or
information regarding imminent danger to yourself or others, which we will report to the appropriate local and State
agency. Additionally, HHS may see your information if we are audited. Finally, the Certificate of Confidentiality does not
imply the endorsement or the disapproval of the HHS.
State/Tribal TUP-S 3-Month (Core and RCT)
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17

Risks: Completing this interview poses few, if any, risks to you. Some questions may make you feel uncomfortable. You can
choose not to answer any question for any reason. You may choose to stop the survey at any time, or not answer a question
for whatever reason. You will not be penalized for stopping. You can contact the principal investigator of the project at
any time. If you stop the interview, at your request, we will destroy your survey.
Benefits: Your participation will not result in any direct benefits to you. However, your input will contribute to a national
effort to prevent suicide.
I am not an expert in the subject matter, and I do not work for the people who provided the training, so please feel free to
respond honestly. There aren’t any wrong answers. We’re just interested in your thoughts and opinions.
Compensation: You will receive a $10 Amazon gift code or money order for participating in this survey.
Contact Information: If you have any concerns about completing this survey or have any questions about the study, please
contact Christine Walrath, principal investigator, at (212) 941-5555 or [email protected].
Do you have any questions?
Do you agree to participate in this interview?



Yes
No

IF YES, continue.
Can you confirm that you are over 18 years of age?



Yes
No

IF YES, continue.
Thank you in advance for your willingness to participate. This call may be recorded and/or monitored for quality
assurance purposes.
Great, thanks. To begin, I’m going to ask you some questions about the knowledge you gained at the training.
1. About 3 months ago, you participated in a training regarding suicide prevention, correct?
Three months ago was [today’s date – 3 months].

Yes

No
Now that it has been about 3 months since your training, we want to know how well you think the [INSERT TRAINING
NAME] has helped in your work, home, or community. [Interviewer Instructions: If asked, the setting of interest is the one
where they are most likely to use their training.]

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18

Part 1. I’d like to start by asking some questions about your training experience and use of what you learned at the training.
2. Have you used your training to do any of the following? (Select all that apply.)

Yes
a. Screen youths for suicidal behaviors (i.e., using a screening tool)

No
b. Formally publicize information about suicide prevention or mental health

I have not used my
resources
training
c. Have informal conversations about suicide and suicide prevention with youths
and others

Not applicable
d. Identify youths who might be at risk for suicide

Don’t know (DK)
e. Provide direct services to youths at risk for suicide and/or their families

Refused
f. Train other staff members to intervene with youths at risk for suicide
g. Make referrals to mental health services for at-risk youths
h. Work with adult at-risk populations
2.1 Have you used the suicide prevention training to do anything I did not

Yes
previously mention?

No
2.2 [IF YES] Could you please describe what you did?

DK

Refused

Gave response

DK

Refused
3. Please rate the following statements about the suicide prevention training.
a. The training increased my knowledge about suicide prevention.
b. The training materials I received (i.e., brochures, wallet cards) have been very
useful for my suicide prevention efforts.
c. The training has met my suicide prevention needs.
d. The training addressed cultural differences in the youth I serve.
e. The training has proven practical to my work and/or my daily life.
f. I have used my training to help with youth suicide prevention in my community.
g. The things I learned during the training have helped me prevent youth suicide or
reduce the problems that might lead to suicide (i.e., depression, substance use).









Strongly agree
Agree
Disagree
Strongly disagree
Not applicable
DK
Refused

4. Did you receive any materials or resources at the training?






Yes
No
DK
Refused







Yes
No
DK
Refused






Yes
No
DK
Refused

4.1 [IF YES] Could you please describe the materials or resources provided at
the training?

5. Did the training you attended include a role-play component or behavioral
rehearsal based on the skills learned during the training?

5.1 [IF YES] Did you participate in a role-play or other type of behavioral
rehearsal during the training you attended?

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19

6. In the last 3 months, how many trainings or presentations about suicide or
suicide prevention have you attended? [Please do not include booster or
refreshers of the training in which you consented to participate in this survey.]








1–5
6–10
11–20
None
DK
Refused






Yes
No
DK
Refused






Yes
No
DK
Refused

9. Have you received any training to support your ability to track or monitor
youths you identified as at risk for suicide?






Yes
No
DK
Refused

10. Please rate the following statements about the suicide prevention training.
a. The training has helped me develop stronger social and familial relationships.
b. The training has helped me connect to members of the community.
c. As a result of the training, I place greater value on connections to friends and
family.
d. The training showed me the importance of high self-esteem and self-confidence.
e. As a result of the training, I am more aware of the importance of
communication.
f. As a result of the training, I have a greater sense of competence.
g. As a result of the training, I have a stronger sense of well-being.










Strongly agree
Agree
Disagree
Strongly disagree
Not applicable
DK
Refused

11. For each of the following statements, please tell me how you would rate your
knowledge
a. Facts concerning suicide prevention.
b. Warning signs of suicide.
c. How to ask someone about suicide.
d. Persuading someone to get help.
e. How to get help for someone.
f. Information about resources for help with suicide.
12. How appropriate do you think it is to ask someone who may be at risk for
suicide about suicide?








Very high
High
Low
Very low
DK
Refused





Very appropriate
Appropriate
Somewhat
appropriate
Not at all
appropriate
DK
Refused

6.1 [If more than 1] Which training(s) about suicide or suicide prevention have
you received?
7. [If more than 1] Have you received any booster training in suicide prevention in
the last 3 months? [We mean booster or refresher sessions directly related to the
training at which you consented to participate in this survey.]
7.1 [IF YES] Which booster training(s) have you received?
8. Since participating in the training, have you used any online tools or
applications (apps) to support what you learned from the training?
8.1 If so, could you please describe the online tools or apps?





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13. What is the likelihood you will ask someone who appears to be at risk if they
are thinking of suicide?








Very likely
Likely
Somewhat likely
Not at all likely
DK
Refused

14. Please read each statement and use the rating scale to indicate the degree to
which you agree or disagree with it. It is important that you answer all
statements according to your beliefs and not what you think others may want
you to believe.
a. If someone I knew was showing signs of suicide, I would directly raise the
question of suicide with them.
b. 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.
c. If someone told me they were thinking of suicide, I would intervene.
d. I feel confident in my ability to help a suicidal person.
e. I don’t think I can prevent someone from suicide.
f. I don’t feel competent to help a person at risk of suicide.
15. In the 3 months since your training, have you used the suicide prevention
training to identify youths you thought might be at risk for suicide?
Three months ago was [today’s date – 3 months].









Strongly agree
Agree
Disagree
Strongly disagree
Not applicable
DK
Refused







Yes
No
DK
Refused






Provide number
None
DK
Refused

15.1 [IF YES] About how many youths have you identified in the last 3
months?

[If identifications are greater than one] The following questions refer to the most recent occasion when you identified a
youth at risk for suicide.
16. Thinking about the youth you identified most recently, did you ask the youth

Yes
whether she/he was considering suicide?

No

17. Thinking about the youth you identified most recently, in which of the following
settings was that youth identified?
17.1 [IF SOME OTHER PLACE] And what was the other place?




DK
Refused





School
Child welfare agency
Juvenile justice
agency
Law enforcement
agency
Physical health
agency (e.g., primary
care, pediatrician’s
office)
Emergency response
unit or emergency
room
Mental health agency







State/Tribal TUP-S 3-Month (Core and RCT)
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21




Community-based
organization,
recreation, or after
school activity
Home
Digital medium (e.g.,
Facebook or text
message)
Some other place
(specify)
DK
Refused

18. Thinking about the youth you identified most recently, did you refer him or her
to get further assistance or support?






Yes
No
DK
Refused

18.1 [IF YES] About how many youths did you refer for further assistance or
support?






Provide number
None
DK
Refused

18.2 [IF YES] Thinking about the youth you identified most recently, to what
services, resources, or individuals did you refer him or her?







Mental health agency
Psychiatric
hospital/unit
Emergency room
Substance abuse
treatment center
School counselor
Private mental health
practice
Mobile crisis unit
Did not refer to
another place
because you
provided services
directly to youth
Some other place
(specify)
DK
Refused






Yes
No
DK
Refused








18.3 And what type of place is this?










19. Thinking about the youth you identified most recently, did you notify that
referral resource about the referral?

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22

20. Thinking about the youth you identified most recently, did you take the youth to
the service or resources you were recommending?






Yes
No
DK
Refused

21. Thinking about the youth you identified most recently, did you reach out to the
youth, his or her family, or service provider to ensure that the youth had access
to mental health services or other support services?






Yes
No
DK
Refused

22. Thinking about the youth you identified most recently, did you receive a formal
confirmation that the youth received the service?






Yes
No
DK
Refused

23. Did the youth receive the services to which he/she was referred?






Yes
No
DK
Refused





Very satisfied
Somewhat satisfied
Neither satisfied nor
dissatisfied
Somewhat dissatisfied
Very dissatisfied
DK
Refused

23.1 [IF DK] Why don’t you know if the youth received services?

24. Think back to the most recent youth you identified who actually received
services, how satisfied are you that your training and the actions you took on
the basis of your training were appropriate and effective?





[Skip if DK whether youth received service.]
25. Thinking about this same youth, about how many days did it take from the time
you made the referral to when the youth received his or her first service?









[Skip if DK whether youth received service.]



26. Again, thinking about this same youth, what was the first service he or she
received? Was it one of the following?



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23

Less than 1 day
Less than 1 week
Between 1 and 2
weeks
More than 2 weeks
and up to 4 weeks
More than 1 month
DK
Refused
Mental health
assessment
Substance use
assessment




Mental health
counseling
Substance abuse
counseling
Inpatient or
residential
psychological services
Psychiatric services or
medication
management without
therapy
Some other service I
have not mentioned
DK
Refused

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






Yes
No
DK
Refused

[Skip if DK whether youth received service.]



Mental health
assessment
Substance use
assessment
Mental health
counseling
Substance abuse
counseling
Inpatient services or
residential
psychological services
Psychiatric services or
medication
management without
therapy
Some other service I
have not mentioned
DK
Refused

26.1 [IF SOME OTHER SERVICE] And could you please describe this other
service to me?









[Skip if DK whether youth received service.]

28. What additional mental health services did he or she receive?
28.1 [IF SOME OTHER SERVICE] Could you please describe this other service to
me?











Our final set of questions is about your personal background.
29. You indicated that XXX was the primary setting in which you interact with
youth. Has the primary setting in which you interact with youths change since
then?
29.1 [IF YES] Please indicate the primary setting in which you interact with
youths.

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24







Education (K-12)
Substance abuse
Juvenile
justice/Probation
Emergency response
Higher education
(college/university)









30. Within that setting, please select the ONE ROLE that you feel best describes
you.
Enhanced:
You indicated that role that best describes you is XXXX. Has your role changed?
[IF YES] Please describe the one role.

Tribal services/tribal
government
Child welfare
Mental health
Primary health care
(other than mental
health)
Other community
settings
DK
Refused

If education (K–12)

Teacher

School administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel

Academic advisor

Tutor
If substance abuse

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel
If juvenile justice/probation

Program/System
administrator

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25








Probation officer
Social worker/Case
worker/Care
coordinator
Detention facility
guard
Program evaluator
Administrative
assistant/Clerical
support personnel

If emergency response

Police officer or other
law enforcement staff

Program/System
administrator

Emergency medical
technician

Fire fighter

Program evaluator

Administrative
assistant/Clerical
support personnel
If higher education
(college/university)

Faculty/Professor/
Researcher

Administrator (e.g.,
dean’s office, vice
president, provost)

Residential life staff

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel

Student

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26

If tribal services/tribal
government

Traditional tribal
healer

Tribal elder

Elected tribal official

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Community outreach
worker

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel
If child welfare

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel
If mental health

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator
State/Tribal TUP-S 3-Month (Core and RCT)
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27





Emergency/Crisis
care worker
Program evaluator
Administrative
assistant/Clerical
support personnel

If primary health care (other
than mental health)

Program/System
administrator

Physician

Nurse

Nursing
assistant/Health
technician

Program evaluator

Administrative
assistant/Clerical
support personnel
If other community settings

Parent or
foster/Resource
parent

Other caregiver

Relative

Youth mentor

Volunteer (i.e., Big
Brother Big Sister,
Court Appointed
Special Advocates
[CASA])

Youth advocate

Clergy/Religious
educator

Other (please
specify):
_________________

DK

Refused
31. About how many other peers/colleagues in that setting have received training
in suicide prevention?

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28








None
1–25%
26–50%
51–75%
76–100%
DK



Refused

32. Please rate the following statement: My peers/colleagues have used the skills
learned from the suicide prevention trainings they participated in.









Strongly agree
Agree
Disagree
Strongly disagree
Not applicable
DK
Refused

33. [Recall setting where trainee interacts with youths] Are there clear, widely used
steps that should be followed after a youth is identified at risk for suicide?






Yes
No
DK
Refused

34. [Recall setting where trainee interacts with youths] Are there clear, widely used
steps that should be followed after a referral is made to make sure the youth
received the services?






Yes
No
DK
Refused

35. Is there an established, shared protocol regarding steps that should be followed
after identification?






Yes
No
DK
Refused

36. In the 3 months since your training, have you shared information from the
training with any of the following? (Select all that apply.) Three months ago
was [today’s date – 3 months].













Youth
Student
Work colleague
Friend
Neighbor
DK
Refused
Shared printed
materials
Shared information
verbally
Shared information
via training or
presentation
DK
Refused





0–15 minutes
16–30 minutes
31 minutes–1 hour

36.1 [IF YES] How did you share the information?




37. What conditions have helped to facilitate the implementation of suicide
prevention activities in that setting?
38. What conditions have hindered the implementation of suicide prevention
activities in that setting?
39. On a typical day, about how much time do you spend interacting or talking
directly with youths?

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29









1–2 hours
Up to 3 hours
Up to 4 hours
Up to 5 hours
More than 5 hours
DK
Refused









Teaching
Counseling/advising
Providing mental
health services
Case management
(e.g., child welfare,
juvenile justice)
Volunteer/Mentoring
(e.g., big brother/
big sister, volunteer)
No formal work;
interactions with youth
are intermittent within
the community setting
Church/spiritual
advisor
Neighbor
DK
Refused

41. Please consider your relationships with youths in responding to the following
items:
a. Youths talk to me about their thoughts and feelings.
b. Youths come to me for advice and assistance when they are troubled.
c. Youths turn to me when they are concerned about another peer.









Never
Seldom
Sometimes
Nearly always
Always
DK
Refused

42. Do you know anyone who has died by suicide? [If no baseline, i.e., core]






Yes
No
DK
Refused









Family
Friend
Coworker
Patient
Neighbor
Acquaintance
Youth

40. What is the nature of your interactions or work with youths?
Enhanced: You indicated that you primarily interact with youth in XX context
(pull from baseline survey). Has this changed?
[If yes] What is the nature of your interactions or work with youth?









42.1 [IF YES] What was your relationship to this person or these persons? (Select
all that apply.)

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



43. What is your gender?










Other (please
specify)
_________________
DK
Refused
Female
Male
Transmale
Transfemale
Gender
nonconforming
Other
DK
Refused

44. What is your age?

Age: ______

DK

Refused

45. Are you Hispanic or Latino?






Yes
No
DK
Refused



Mexican, Mexican
American, or Chicano
Puerto Rican
Cuban
Dominican
Central American
South American
Other Hispanic or
Latino
DK
Refused

45.1 [IF YES] Which group represents you? (Select all that apply.)









46. What is your race? (Select all that apply.)










State/Tribal TUP-S 3-Month (Core and RCT)
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31

American Indian or
Alaska Native
Asian
Black or African
American
Native Hawaiian or
other Pacific Islander
White
Other
DK
Refused

47. I would like to offer you one of two ways to receive your $10 honorarium. I can
either give it to you now over the phone as an Amazon.com gift code, or I can
confirm your address and send it as a money order. Which would you prefer?
(If money order is selected interviewer will confirm mailing address with the
information we have on file.)
48. Are you willing to be contacted again in 3 months to answer some further
follow-up questions about how you’ve used the information and skills you
learned in the training?




Yes
No

Thank you very much for your time today. Your information will be very valuable to SAMHSA in its efforts to reduce
suicide among youths. If you have any questions or concerns about this survey,
please contact Christine Walrath, ICF International, at (646) 695-8154.

State/Tribal TUP-S 3-Month (Core and RCT)
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Attachment E-3: TUP-S 6 Month (Core-RCT) State Tribal

Garrett Lee Smith (GLS) National Outcomes Evaluation
State/Tribal Suicide Prevention Program
Training Utilization and Preservation Survey (TUP-S) and Verbal Consent Script
6–Month Version (Core and RCT)
Hello, my name is [INSERT INTERVIEWER NAME], and I’m calling to speak with you about the training that you attended
on [INSERT TRAINING DATE]. Is now a good time for you to talk?
IF NO: Is there a better time to call back?
IF YES: Great! As I said, my name is [INSERT INTERVIEWER NAME], and I work for ICF International, a company that has
been contracted by SAMHSA (which stands for the Substance Abuse and Mental Health Services Administration) to conduct
the National Outcomes Evaluation of GLS suicide prevention programs across the country. As part of this evaluation, we are
interviewing a random sample of people who have attended suicide prevention trainings sponsored by GLS State and
Tribal grantees. We hope to learn more about the trainings, how you have used what you learned, and the impact of the
training on you and your interactions with your peers.
On [DATE OF TRAINING], you participated in a training called [INSERT TRAINING NAME] as part of the State/Tribal
component of the GLS Youth Suicide Prevention and Early Intervention Program. You participated in a follow-up survey
about 3 months ago. At the end of the survey, you consented to be contacted again in 3 months for an additional follow-up
survey. We are contacting you now to administer the survey. This survey asks questions about the training, how you have
used what you learned during the training, and your satisfaction with the training. Findings from this survey will help inform
SAMHSA about suicide prevention activities.
The survey will take approximately 25 minutes to complete and you will receive $10 for your participation. If you are
interested, I will give you some more information and request your verbal consent.
Before I ask you whether you agree to be interviewed, there are a few more things that you should know.
Rights Regarding Participation: Your input is important; however, your participation in this survey is completely voluntary.
There are no penalties or consequences for not participating. You can choose to stop the interview at any time, or not
answer a question for whatever reason. If you stop the interview, at your request, we will destroy the survey. You may ask
any questions that you have before, during, or after you complete the survey. May I continue?
Privacy: Your answers are private and will not be linked to your name. Your name will never appear in any report that
summarizes the findings of the National Outcomes Evaluation. All findings will be reported in aggregate; that is, they will
be combined with responses from other individuals.
Additional Protection: In addition, to protect the information that you give us, we have applied for a Certificate of
Confidentiality from the U.S. Department of Health and Human Services (HHS). The Certificate of Confidentiality will
protect the members of the research staff from being forced, even under a subpoena, to release any information in which
you are identified. Exceptions to the Certificate of Confidentiality are information on child abuse and neglect, or
information regarding imminent danger to yourself or others, which we will report to the appropriate local and State
agency. Additionally, HHS may see your information if we are audited. Finally, the certificate of confidentiality does not
imply the endorsement or the disapproval of the HHS.
Risks: Completing this interview poses few, if any, risks to you. Some questions may make you feel uncomfortable. You can
choose not to answer any question for any reason. You may choose to stop the survey at any time, or not answer a question
State/Tribal TUP-S 6-Month (Core and RCT)
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34

for whatever reason. You will not be penalized for stopping. You can contact the principal investigator of the project at
any time. If you stop the interview, at your request, we will destroy your survey.
Benefits: Your participation will not result in any direct benefits to you. However, your input will contribute to a national
effort to prevent suicide.
I am not an expert in the subject matter, and I do not work for the people who provided the training, so please feel free to
respond honestly. There are no wrong answers. We're just interested in your thoughts and opinions.
Compensation: You will receive a $10 Amazon gift code or money order for participating in this survey.
Contact Information: If you have any concerns about completing this survey or have any questions about the study, please
contact Christine Walrath, principal investigator, at (212) 941-5555 or [email protected].
Do you have any questions?
Do you agree to participate in this interview?



Yes
No

IF YES, continue.
Can you confirm that you are over 18 years of age?



Yes
No

IF YES, continue.
Thank you in advance for your willingness to participate. This call may be recorded and/or monitored for quality
assurance purposes.
To begin, I’m going to ask you some questions about the knowledge you gained at the training.
37. About 6 months ago, you participated in a training regarding suicide prevention, correct?
Six months ago was [today’s date – 6 months].

Yes

No
Now that it has been about 6 months since your training, we want to learn about how the [INSERT TRAINING NAME] has
impacted your work, home, or community. [Interviewer Instructions: If asked, the setting of interest is the one where they
are most likely to use their training]

Part 1. I’d like to start by asking some questions about your training experience and use of what you learned at the training.
38. In the last 3 months, have you used your training to do any of the following?
State/Tribal TUP-S 6-Month (Core and RCT)
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

Yes

(Select all that apply.)
i. Screen youths for suicidal behaviors (i.e., using a screening tool)
j. Formally publicize information about suicide prevention or mental health
resources
k. Have informal conversations about suicide and suicide prevention with youths
and others
l. Identify youths who might be at risk for suicide
m. Provide direct services to youth at risk for suicide and/or their families
n. Train other staff members to intervene with youths at risk for suicide
o. Make referrals to mental health services for at-risk youths
p. Work with adult at-risk populations
38.1
In the last 3 months, have you used the suicide prevention training to
do anything I did not previously mention?
38.2
[IF YES] Could you please describe what you did?





No
I have not used my
training
NOT APPLICABLE
Don’t know (DK)
REFUSED



















Yes
No
DK
REFUSED
Gave response
DK
REFUSED
1–5
6–10
11–20
None
DK
REFUSED
Yes
No
DK
REFUSED






Yes
No
DK
REFUSED






Yes
No
DK
REFUSED

43. For each of the following statements, please tell me how you would rate your
knowledge:
g. Facts concerning suicide prevention.
h. Warning signs of suicide.
i. How to ask someone about suicide.
j. Persuading someone to get help.
k. How to get help for someone.
l. Information about resources for help with suicide.








Very high
High
Low
Very low
DK
REFUSED

44. How appropriate do you think it is to ask someone who may be at risk for
suicide about suicide?





Very appropriate
Appropriate
Somewhat appropriate

39. In the last 3 months, how many trainings or presentations about suicide or
suicide prevention have you attended? [Please do not include booster or
refreshers of the training in which you consented to participate in this survey.]
3.1 [If more than one] Which training(s) about suicide or suicide prevention
have you received?
40. [If more than 1] Have you received any booster training in suicide prevention
in the last 3 months? [We mean booster or refresher sessions directly related to
the training in which you consented to participate in this survey.]
4.1 [IF YES] Which booster training(s) have you received?
41. Since participating in the training, have you used any online tools or
applications (apps) to support what you learned from the training?
5.1 [If so] Could you please describe the online tools or apps?
42. Have you received any training to support your ability to track or monitor
youths you identified as at risk for suicide?




Part 2. The following questions are about the information you learned at the training.

State/Tribal TUP-S 6-Month (Core and RCT)
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



Not at all appropriate
DK
REFUSED

45. What is the likelihood you will ask someone who appears to be at risk if they
are thinking of suicide?








Very likely
Likely
Somewhat likely
Not at all likely
DK
REFUSED

46. Please read each statement and use the rating scale to indicate the degree to
which you agree or disagree with it. It is important that you answer all
statements according to your beliefs and not what you think others may want
you to believe.
g. If someone I knew was showing signs of suicide, I would directly raise the
question of suicide with them.
h. 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.
i. If someone told me they were thinking of suicide, I would intervene.
j. I feel confident in my ability to help a suicidal person.
k. I don’t think I can prevent someone from suicide.
l. I don’t feel competent to help a person at risk of suicide.
Part 3. The next set of questions ask about your experiences with youths at risk for suicide.
47. In the last 3 months, have you used the suicide prevention training to identify
youths you thought might be at risk for suicide?
Three months ago was [today’s date – 3 months].









Strongly agree
Agree
Disagree
Strongly disagree
NOT APPLICABLE
DK
REFUSED

 Yes
 No
 DK
 REFUSED
11.1 [IF YES] About how many youths have you identified in the last 3
 Provide number
months?
 None
 DK
 REFUSED
[IF identifications are greater than one] The following questions refer to the most recent occasion when you identified a youths
at risk for suicide.
48. Thinking about the youth you identified most recently, did you ask the youth

Yes
whether she/he was considering suicide?

No

DK

REFUSED
49. Thinking about the youth you identified most recently, in which of the
 School
following settings was that youth identified?
 Child welfare agency
 Juvenile justice agency
13.1 [IF SOME OTHER PLACE] And what was the other place?
 Law enforcement
agency
Physical health agency
(e.g., primary care,
pediatrician’s office)
 Emergency response
unit or emergency
room
 Mental health agency
 Community-based
organization,
State/Tribal TUP-S 6-Month (Core and RCT)
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


recreation, or afterschool activity
Home
Digital medium (e.g.,
Facebook or text
message)
Some other place
(SPECIFY) ________
DK
REFUSED
Yes
No
DK
REFUSED
Provide number
None
DK
REFUSED
Mental health agency
Psychiatric
hospital/unit
Emergency room
Substance abuse
treatment center
School counselor
Private mental health
practice
Mobile crisis unit
Did not refer to
another place because
you provided services
directly to youth
Some other place
(SPECIFY) ________
DK
REFUSED

51. Thinking about the youth you identified most recently, did you notify that
referral resource about the referral?






Yes
No
DK
REFUSED

52. Thinking about the youth you identified most recently, did you take the youth
to the service or resources you were recommending?






Yes
No
DK
REFUSED

53. Thinking about the youth you identified most recently, did you reach out to the
youth, his or her family, or service provider to ensure that the youth had access
to mental health services or other support services?






Yes
No
DK
REFUSED

54. Thinking about the youth you identified most recently, did you receive a formal



Yes





50. Thinking about the youth you identified most recently, did you refer the youth
you identified to get further assistance or support?

14.1 [IF YES] About how many youths that you have identified did you refer
for further assistance or support?

14.2 [IF YES] Thinking about the youth you identified most recently, to what
services, resources, or individuals did you refer the youth?
14.3 And what type of place is this?






















State/Tribal TUP-S 6-Month (Core and RCT)
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38

confirmation that the youth received the service?

55. Did the youth receive the services to which he/she was referred?





No
DK
REFUSED






Yes
No
DK
REFUSED





Very satisfied
Somewhat satisfied
Neither satisfied nor
dissatisfied
Somewhat dissatisfied
Very dissatisfied
DK
REFUSED
Less than 1 day
Less than 1 week
Between 1 and 2
weeks
More than 2 weeks
and up to 4 weeks
More than 1 month
DK
REFUSED
Mental health
assessment
Substance use
assessment
Mental health
counseling
Substance abuse
counseling
Inpatient or residential
psychological services
Psychiatric services or
medication
management without
therapy
Some other service I
have not mentioned
DK
REFUSED

19.1 [IF DK] Why don’t you know if the youth received services?
56. Thinking back to the most recent youth you identified who actually received
services, how satisfied are you that your training and the actions you took on
the basis of your training were appropriate and effective?

[Skip if DK whether youth received service.]
57. Thinking about this same youth, about how many days did it take from the
time you made the referral to when the youth received his or her first service?














[Skip if DK whether youth received service.]
58. Again, thinking about this same youth, what was the first service he or she
received? Was it one of the following?
22.1 [IF SOME OTHER SERVICE] And could you please describe this other
service to me?











State/Tribal TUP-S 6-Month (Core and RCT)
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39

[Skip if DK whether youth received service.]

Yes
No
59. Did he or she receive any additional mental health services since that first
DK
appointment?
REFUSED
[Skip if DK whether youth received service.]
Mental health
assessment
60. What additional mental health services did he or she receive?
 Substance use
assessment
24.1 [IF SOME OTHER SERVICE] Could you please describe this other service to
 Mental health
me?
counseling
 Substance abuse
counseling
 Inpatient services or
residential
psychological services
 Psychiatric services or
medication
management without
therapy
 Some other service I
have not mentioned
 DK
 REFUSED
Part 4. The next set of questions is about your personal background and experience with individuals in crisis.
61. You indicated that XXX was the primary setting in which you interact with

Education (K-12)
youths. Has the primary setting in which you interact with youths change since
 Substance abuse
then?
 Juvenile
justice/Probation
25.1 [IF YES] Please indicate the primary setting in which you interact with

Emergency response
youths.
 Higher education
(college/university)
 Tribal services/Tribal
government
 Child welfare
 Mental health











State/Tribal TUP-S 6-Month (Core and RCT)
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40

Primary health care
(other than mental
health)
Other community
settings
DK
REFUSED

62. You indicated that role that best describes you is XXXX. Has your role changed?
26.1 [IF YES] Please describe the one role.

If education (K–12)
 Teacher
 School administrator
 Mental health
clinician/Counselor/
Psychologist
 Social worker/Case
worker/Care
coordinator
 Emergency/Crisis care
worker
 Program evaluator
 Administrative
assistant/Clerical
support personnel
 Academic advisor
 Tutor
If substance abuse
 Program/System
administrator
 Mental health
clinician/Counselor/
Psychologist
 Social worker/Case
worker/Care
coordinator
 Emergency/Crisis care
worker
 Program evaluator
 Administrative
assistant/Clerical
support personnel
If juvenile justice/probation
 Program/System
administrator
 Probation officer
 Social worker/Case
worker/Care
coordinator
 Detention facility
guard
 Program evaluator
Administrative
assistant/Clerical
support personnel
If emergency response

Police officer or other
law enforcement staff

Program/System
administrator

State/Tribal TUP-S 6-Month (Core and RCT)
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




Emergency medical
technician
Fire fighter
Program evaluator
Administrative
assistant/Clerical
support personnel

If higher education
(college/university)
 Faculty/Professor/
Researcher
 Administrator (e.g.,
dean’s office, vice
president, provost)
 Residential life staff
 Mental health
clinician/Counselor/
Psychologist
 Social worker/Case
worker/Care
coordinator
 Emergency/Crisis care
worker
 Program evaluator
 Administrative
assistant/Clerical
support personnel
 Student
If tribal services/tribal
government
 Traditional tribal
healer
 Tribal elder
 Elected tribal official
 Program/System
administrator
 Mental health
clinician/Counselor/
Psychologist






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42

Social worker/Case
worker/Care
coordinator
Community outreach
worker
Emergency/Crisis care
worker
Program evaluator
Administrative
assistant/Clerical
support personnel

If child welfare
 Program/System
administrator
 Mental health
clinician/Counselor/
Psychologist
 Social worker/Case
worker/Care
coordinator
 Emergency/Crisis care
worker
 Program evaluator
 Administrative
assistant/Clerical
support personnel
If mental health
 Program/System
administrator
 Mental health
clinician/Counselor/
Psychologist
 Social worker/Case
worker/Care
coordinator
 Emergency/Crisis care
worker
 Program evaluator
 Administrative
assistant/Clerical
support personnel
If primary health care (other
than mental health)
 Program/System
administrator
 Physician
 Nurse
 Nursing
assistant/Health
technician
 Program evaluator
 Administrative
assistant/Clerical
support personnel
If other community settings
 Parent or
foster/Resource parent
 Other caregiver
 Relative
 Youth mentor
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









Volunteer (i.e., Big
Brother Big Sister,
CASA)
Youth advocate
Clergy/Religious
educator
OTHER (please
specify): ___________
DK
REFUSED
None
1–25%
26–50%
51–75%
76–100%
DK
REFUSED

64. Please rate the following statement: My peers/colleagues have used the skills
learned from the suicide prevention trainings in which they participated?









Strongly agree
Agree
Disagree
Strongly disagree
NOT APPLICABLE
DK
REFUSED

65. [Recall setting where trainee interacts with youths] Are there clear, widely used
steps that should be followed after a youth is identified as at risk for suicide?














Yes
No
DK
REFUSED
Yes
No
DK
REFUSED
Yes
No
DK
REFUSED










Youth
Student
Work colleague
Friend
Neighbor
DK
REFUSED
Shared printed
materials
Shared information
verbally






63. About how many other peers/colleagues in that setting have received training
in suicide prevention?

66. [Recall setting where trainee interacts with youth] Are there clear, widely used
steps that should be followed after a referral is made to make sure the youth
received the services?
67. Is there an established, shared protocol regarding steps that should be
followed after identification?

68. In the last 3 months, have you shared information from the training with any
of the following? (Select all that apply) Three months ago was [today’s date–3
months].
32.1 [IF YES] How did you share the information?


State/Tribal TUP-S 6-Month (Core and RCT)
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44





Shared information via
training or presentation
DK
REFUSED

33. What conditions have helped to facilitate the implementation of suicide
prevention activities in that setting?
34. What conditions have hindered the implementation of suicide prevention
activities in that setting?
35. On a typical day, about how much time do you spend interacting or talking
directly with youths?





0–15 minutes
16–30 minutes
31 minutes–1 hour
1–2 hours
Up to 3 hours
Up to 4 hours
Up to 5 hours
More than 5 hours
DK
REFUSED
Teaching
Counseling/Advising
Providing mental
health services
Case management
(e.g., child welfare,
juvenile justice)
Volunteer/Mentoring
(e.g., big brother/big
sister, volunteer)
No formal work;
interactions with youths
are intermittent within
the community setting
Church/Spiritual
advisor
Neighbor
DK
REFUSED

37. Please consider your relationships with youths in responding to the following
items:
d. Youths talk to me about their thoughts and feelings.
e. Youths come to me for advice and assistance when they are troubled.
f. Youths turn to me when they are concerned about another
peer.









Never
Seldom
Sometimes
Nearly always
Always
DK
REFUSED

38. Do you know anyone who has died by suicide? [If no baseline, i.e., core]






Yes
No
DK
REFUSED

Enhanced: You indicated that you primarily interact with youth in XX context (pull
from baseline survey). Has this changed?















[If yes] What is the nature of your interactions or work with youths?



36. What is the nature of your interactions or work with youths?






State/Tribal TUP-S 6-Month (Core and RCT)
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45

38.1 [IF YES] What was your relationship to this person or these persons?
(Select all that apply)




Family
Friend
Coworker
Patient
Neighbor
Acquaintance
Youth
Other (please specify)
_________________
DK
REFUSED




Yes
No










Wrap-up: This is the last set of questions.
39. I would like to offer you one of two ways to receive your $10 honorarium. I can
either give it to you now over the phone as an Amazon.com gift code, or I can
confirm your address and send it as a money order. Which would you prefer?
(If money order is selected, interviewer will confirm mailing address with the information we
have on file.)
40. Are you willing to be contacted again in 3 months to answer some further
follow-up questions about how you’ve used the information and skills you
learned in the training?

Thank you very much for your time today. Your information will be very valuable to SAMHSA in its efforts to reduce
suicide among youths. If you have any questions or concerns about this survey,
please contact Christine Walrath, ICF International, at (646) 695-8154.

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46

Attachment E-4: TUP-S 12 Month (RCT) State Tribal

OMB No. XXXX-XXXX
Expiration Date: Date
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 XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 25 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.

Garrett Lee Smith (GLS) National Outcomes Evaluation
State/Tribal Suicide Prevention Program
Training Utilization and Preservation Survey (TUP-S) and Verbal Consent Script
12–Month Version (RCT)
Hello, my name is [INSERT INTERVIEWER NAME], and I’m calling to speak with you about the training that you attended
on [INSERT TRAINING DATE]. Is now a good time for you to talk?
IF NO: Is there a better time to call back?
IF YES: Great! As I said, my name is [INSERT INTERVIEWER NAME], and I work for ICF International, a company that has
been contracted by SAMHSA (which stands for the Substance Abuse and Mental Health Services Administration) to conduct
the National Outcomes Evaluation of GLS suicide prevention programs across the country. As part of this evaluation, we are
interviewing a random sample of people who have attended suicide prevention trainings sponsored by GLS State and
Tribal grantees. We hope to learn more about the trainings, how you have used what you learned, and the impact of the
training on you and your interactions with your peers.
On [DATE OF TRAINING], you participated in a training called [INSERT TRAINING NAME] as part of the State/Tribal
component of the GLS Youth Suicide Prevention and Early Intervention Program. You participated in a follow-up survey
about 6 months ago. At the end of the survey, you consented to be contacted again in 6 months for an additional follow-up
survey. We are contacting you now to administer the survey. This survey asks questions about the training, how you have
used what you learned during the training, and your satisfaction with the training. Findings from this survey will help inform
SAMHSA about suicide prevention activities.
The survey will take approximately 25 minutes to complete and you will receive $10 for your participation. If you are
interested, I will give you some more information and request your verbal consent.
Before I ask you whether you agree to be interviewed, there are a few more things that you should know.
Rights Regarding Participation: Your input is important; however, your participation in this survey is completely voluntary.
There are no penalties or consequences for not participating. You can choose to stop the interview at any time, or not
answer a question for whatever reason. If you stop the interview, at your request, we will destroy the survey. You may ask
any questions that you have before, during, or after you complete the survey. May I continue?
Privacy: Your answers are private and will not be linked to your name. Your name will never appear in any report that
summarizes the findings of the National Outcomes Evaluation. All findings will be reported in aggregate; that is, they will
be combined with responses from other individuals.
Additional Protection: In addition, to protect the information that you give us, we have applied for a Certificate of
Confidentiality from the U.S. Department of Health and Human Services (HHS). The Certificate of Confidentiality will
protect the members of the research staff from being forced, even under a subpoena, to release any information in which
you are identified. Exceptions to the Certificate of Confidentiality are information on child abuse and neglect, or
information regarding imminent danger to yourself or others, which we will report to the appropriate local and State

agency. Additionally, HHS may see your information if we are audited. Finally, the certificate of confidentiality does not
imply the endorsement or the disapproval of the HHS.
Risks: Completing this interview poses few, if any, risks to you. Some questions may make you feel uncomfortable. You can
choose not to answer any question for any reason. You may choose to stop the survey at any time, or not answer a
question, for whatever reason. You will not be penalized for stopping. You can contact the principal investigator of the
project at any time. If you stop the interview, at your request, we will destroy your survey.
Benefits: Your participation will not result in any direct benefits to you. However, your input will contribute to a national
effort to prevent suicide.
I am not an expert in the subject matter, and I do not work for the people who provided the training, so please feel free to
respond honestly. There are no wrong answers. We’re just interested in your thoughts and opinions.
Compensation: You will receive a $10 Amazon gift code or money order for participating in this survey.
Contact Information: If you have any concerns about completing this survey or have any questions about the study, please
contact Christine Walrath, principal investigator, at (212) 941-5555 or [email protected].
Do you have any questions?
Do you agree to participate in this interview?
 Yes
 No
IF YES, continue.
Can you confirm that you are over 18 years of age?
 Yes
 No
IF YES, continue.
Thank you in advance for your willingness to participate. This call may be recorded and/or monitored for quality
assurance purposes.
Part I. To begin, I’m going to ask you some questions about the knowledge you gained at the training.
38. About 6 months ago, you participated in a training regarding suicide prevention, correct?
Six months ago was [today’s date – 6 months].
 Yes
 No
Now that it has been about 6 months since your training, we want to learn about how the [INSERT TRAINING NAME] has
impacted your work, home, or community. [Interviewer Instructions: If asked, the setting of interest is the one where they
are most likely to use their training.]

State/Tribal TUP-S 12-Month (RCT)
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49

Part 1. I’d like to start by asking some questions about your training experience and use of what you learned at the training.
69. In the last 6 months, have you used your training to do any of the following?
(Select all that apply.)
q.
r.
s.
t.
u.
v.
w.
x.

Screen youths for suicidal behaviors (i.e., using a screening tool)
Formally publicize information about suicide prevention or mental health resources
Have informal conversations about suicide and suicide prevention with youths and others
Identify youths who might be at risk for suicide
Provide direct services to youths at risk for suicide and/or their families
Train other staff members to intervene with youths at risk for suicide
Make referrals to mental health services for at-risk youths
Work with adult at-risk populations

69.1 In the last 6 months, have you used the suicide prevention training to do anything I did not
previously mention?
69.2 [IF YES] Could you please describe what you did?

70. In the last 6 months, how many trainings or presentations about suicide or
suicide prevention have you attended? [Please do not include booster or
refreshers of the training in which you consented to participate in this survey.]
70.1[If more than one] Which training(s) about suicide or suicide prevention
have you received?
71. [If more than one] Have you received any booster training in suicide prevention
in the last 6 months? [We mean booster or refresher sessions directly related to
the training in which you consented to participate in this survey.]
71.1

[IF YES] Which booster training(s) have you received?

72. Since participating in the training, have you used any online tools or applications (apps) to
support what you learned from the training?

72.1

If so, could you please describe the online tools or apps?

73. Have you received any training to support your ability to track or monitor youths
you identified as at risk for suicide?

Part 2. The following questions are about the information you learned at the training.
74. For each of the following statements, please tell me how you would rate your
knowledge:
m.
n.
o.
p.
q.
r.

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.

State/Tribal TUP-S 12-Month (RCT)
12/2015



Yes



No



I have not used my
training





NOT APPLICABLE
Don’t know (DK)
REFUSED















Yes
No
DK
REFUSED
Gave response
DK
REFUSED
1–5
6–10
11–20
None
DK
REFUSED






Yes
No
DK
REFUSED










Yes
No
DK
REFUSED
Yes
No
DK
REFUSED








Very high
High
Low
Very low
DK
REFUSED

50

75. How appropriate do you think it is to ask someone who may be at risk for
suicide about suicide?






76. What is the likelihood you will ask someone who appears to be at risk if they
are thinking of suicide?

77. Please read each statement and use the rating scale to indicate the degree to
which you agree or disagree with it. It is important that you answer all
statements according to your beliefs and not what you think others may want
you to believe.
m.
n.
o.
p.
q.
r.

If someone I knew was showing signs of suicide, I would directly raise the question of suicide with
them.
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 intervene.
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.

















Very appropriate
Appropriate
Somewhat
appropriate
Not at all
appropriate
DK
REFUSED
Very likely
Likely
Somewhat likely
Not at all likely
DK
REFUSED
Strongly agree
Agree
Disagree
Strongly disagree
NOT APPLICABLE
DK
REFUSED

Part 3. The next set of questions ask about your experiences with youths at risk for suicide.
78. In the last 6 months, have you used the suicide prevention training to identify
youths you thought might be at risk for suicide?
Six months ago was [today’s date – 6 months].


Yes

No

DK

REFUSED

11.1 [IF YES] About how many youths have you identified in the last 6 months?

Provide number

None

DK

REFUSED
[IF identifications is greater than] The following questions refer to the most recent occasion when you identified a youth at risk
for suicide.
79. Thinking about the youth you identified most recently, did you ask the youth

Yes
whether she/he was considering suicide?

No

DK

REFUSED
80. Thinking about the youth you identified most recently, in which of the following

School
settings was that youth identified?

Child welfare
agency
13.1 [IF SOME OTHER PLACE] And what was the other place?

Juvenile justice
agency

Law enforcement
agency

Physical health
agency (e.g.,
State/Tribal TUP-S 12-Month (RCT)
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51









81. Thinking about the youth you identified most recently, did you refer the youth to
get further assistance or support?

14.1 [IF YES] About how many youths that you identified did you refer for
further assistance or support?

14.2 [IF YES] Thinking about the youth you identified most recently, to what
services, resources, or individuals did you refer the youth?
14.3 And what type of place is this?
























State/Tribal TUP-S 12-Month (RCT)
12/2015

primary care,
pediatrician’s office)
Emergency response
unit or emergency
room
Mental health
agency
Community-based
organization,
recreation, or after
school activity
Home
Digital medium (e.g.,
Facebook or text
message)
Some other place
(SPECIFY)
DK
REFUSED
Yes
No
DK
REFUSED
Provide number
None
DK
REFUSED
Mental health
agency
Psychiatric
hospital/unit
Emergency room
Substance abuse
treatment center
School counselor
Private mental
health practice
Mobile crisis unit
Did not refer to
another place
because you
provided services
directly to youth
Some other place
(SPECIFY)
DK
REFUSED

52

82. Thinking about the youth you identified most recently, did you notify that
referral resource about the referral?










Yes
No
DK
REFUSED
Yes
No
DK
REFUSED

84. Thinking about the youth you identified most recently, did you reach out to the
youth, his or her family, or service provider to ensure that the youth had access
to mental health services or other support services?






Yes
No
DK
REFUSED

85. Thinking about the youth you identified most recently, did you receive a formal
confirmation that the youth received the service?










Yes
No
DK
REFUSED
Yes
No
DK
REFUSED





Very satisfied
Somewhat satisfied
Neither satisfied nor
dissatisfied
Somewhat
dissatisfied
Very dissatisfied
DK
REFUSED
Less than 1 day
Less than 1 week
Between 1 and 2
weeks
More than 2 weeks
and up to 4 weeks
More than 1 month
DK
REFUSED
Mental health
assessment
Substance use
assessment
Mental health
counseling
Substance abuse
counseling

83. Thinking about the youth you identified most recently, did you take the youth to
the service or resources you were recommending?

86. Did the youth receive the services to which he/she was referred?

19.1 [IF DK] Why don’t you know if the youth received services?
87. Think back to the most recent youth you identified who actually received
services, how satisfied are you that your training and the actions you took on
the basis of your training were appropriate and effective?



[Skip if DK whether youth received service.]
88. Thinking about this same youth, about how many days did it take from the time
you made the referral to when the youth received his or her first service?









[Skip if DK whether youth received service.]
89. Again, thinking about this same youth, what was the first service he or she
received? Was it one of the following?
22.1 [IF SOME OTHER SERVICE] And could you please describe this other service
to me?

State/Tribal TUP-S 12-Month (RCT)
12/2015









53




Inpatient or
residential
psychological
services
Psychiatric services
or medication
management without
therapy
Some other service I
have not mentioned
DK
REFUSED






Yes
No
DK
REFUSED







[Skip if DK whether youth received service.]
90. Did he or she receive any additional mental health services since that first
appointment?
[Skip if DK whether youth received service.]

Mental health
assessment
91. What additional mental health services did he or she receive?

Substance use
assessment
24.1 [IF SOME OTHER SERVICE] Could you please describe this other service to

Mental health
me?
counseling

Substance abuse
counseling

Inpatient services or
residential
psychological
services

Psychiatric services
or medication
management without
therapy

Some other service I
have not mentioned

DK

REFUSED
Part 4. The next set of questions is about your personal background and experience with individuals in crisis.
92. You indicated that XXX was the primary setting in which you interact with

Education (K-12)
youths. Has the primary setting in which you interact with youths change since

Substance abuse
then?

Juvenile
justice/Probation
25.1 [IF YES] Please indicate the primary setting in which you interact with

Emergency response
youths.

Higher education
(college/university)

Tribal
services/Tribal
government

Child welfare

Mental health

Primary health care
State/Tribal TUP-S 12-Month (RCT)
12/2015



54

(other than mental
health)

Other community
settings

DK

REFUSED
93. You indicated that role that best describes you is XXXX. Has your role changed? If education (K–12)

Teacher
26.1 [IF YES] Please describe the one role.

School administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel

Academic advisor

Tutor
If substance abuse

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel
If juvenile justice/probation

Program/System
administrator

Probation officer

Social worker/Case
worker/Care
coordinator

Detention facility
guard

Program evaluator

Administrative
assistant/Clerical
State/Tribal TUP-S 12-Month (RCT)
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55

support personnel
If emergency response

Police officer or
other law
enforcement staff

Program/System
administrator

Emergency medical
technician

Fire fighter

Program evaluator

Administrative
assistant/Clerical
support personnel
If higher education
(college/university)

Faculty/Professor/R
esearcher

Administrator (e.g.,
dean’s office, vice
president, provost)

Residential life staff

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel

Student
If tribal services/tribal
government

Traditional tribal
healer

Tribal elder

Elected tribal official

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator
State/Tribal TUP-S 12-Month (RCT)
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56



Community outreach
worker



Emergency/Crisis
care worker
Program evaluator
Administrative
assistant/Clerical
support personnel




If child welfare

Program/System
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel
If mental health

Program/system
administrator

Mental health
clinician/Counselor/
Psychologist

Social worker/Case
worker/Care
coordinator

Emergency/Crisis
care worker

Program evaluator

Administrative
assistant/Clerical
support personnel
If primary health care (other
than mental health)

Program/System
administrator

Physician

Nurse

Nursing
assistant/Health
technician

Program evaluator

Administrative
State/Tribal TUP-S 12-Month (RCT)
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57

assistant/Clerical
support personnel

94. About how many other peers/colleagues in that setting have received training in
suicide prevention?

95. Please rate the following statement: My peers/colleagues have used the skills
learned from the suicide prevention trainings in which they participated?

If other community settings

Parent or
foster/Resource
parent

Other caregiver

Relative

Youth mentor

Volunteer (i.e., Big
Brother Big Sister,
Court Appointed
Special Advocates
[CASA])

Youth advocate

Clergy/Religious
educator

OTHER (please
specify):

DK

REFUSED

None

1–25%

26–50%

51–75%

76–100%

DK

REFUSED

Strongly agree

Agree

Disagree

Strongly disagree

NOT APPLICABLE

DK

REFUSED

96. [Recall setting where trainee interacts with youths] Are there clear, widely used
steps that should be followed after a youth is identified as at risk for suicide?






Yes
No
DK
REFUSED

97. [Recall setting where trainee interacts with youths] Are there clear, widely used
steps that should be followed after a referral is made to make sure the youth
received the services?










Yes
No
DK
REFUSED
Yes
No
DK
REFUSED

98. Is there an established, shared protocol regarding steps that should be followed
after identification?

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99. In the 6 months since your training, have you shared information from the
training with any of the following? (Select all that apply) Six months ago was
[today’s date – 6 months].
32.1[IF YES] How did you share the information?














Youth
Student
Work colleague
Friend
Neighbor
DK
REFUSED
Shared printed
materials
Shared information
verbally
Shared information
via training or
presentation
DK
REFUSED

100. What conditions have helped to facilitate the implementation of suicide
prevention activities in that setting?
101. What conditions have hindered the implementation of suicide prevention
activities in that setting?
102. On a typical day, about how much time do you spend interacting or talking
directly with youths?

103.

What is the nature of your interactions or work with youths?

Enhanced: You indicated that you primarily interact with youths in XX context (pull
from baseline survey). Has this changed?
If yes, what is the nature of your interactions or work with youths?





















State/Tribal TUP-S 12-Month (RCT)
12/2015

0–15 minutes
16–30 minutes
31 minutes–1 hour
1–2 hours
Up to 3 hours
Up to 4 hours
Up to 5 hours
More than 5 hours
DK
REFUSED
Teaching
Counseling/Advising
Providing mental
health services
Case management
(e.g., child welfare,
juvenile justice)
Volunteer/Mentoring
(e.g. big brother/big
sister, volunteer)
No formal work;
interactions with
youth are
intermittent within
the community
setting
Church/Spiritual
advisor
Neighbor
DK
59

104. Please consider your relationships with youths in responding to the
following items:
g.
h.
i.

105.

Youths talk to me about their thoughts and feelings.
Youths come to me for advice and assistance when they are troubled.
Youths turn to me when they are concerned about another peer.

Do you know anyone who has died by suicide? [If no baseline, i.e., core]

38.1 [IF YES] What was your relationship to this person or these persons?
(Select all that apply.)



REFUSED









Never
Seldom
Sometimes
Nearly always
Always
DK
REFUSED














Yes
No
DK
REFUSED
Family
Friend
Coworker
Patient
Neighbor
Acquaintance
Youth
Other (please
specify)
DK
REFUSED



Wrap-up: This is the last set of questions.
106. I would like to offer you one of two ways to receive your $10 honorarium. I
can either give it to you now over the phone as an Amazon.com gift code, or I
can confirm your address and send it as a money order. Which would you
prefer?
(If money order is selected, interviewer will confirm mailing address with
information we have on file.)

Thank you very much for your time today. Your information will be very valuable to SAMHSA in its efforts to reduce
suicide among youths. If you have any questions or concerns about this survey,
please contact Christine Walrath, ICF International, at (646) 695-8154.

State/Tribal TUP-S 12-Month (RCT)
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60

Attachment E-5: TUP-S Consent to Contact (Core) State Tribal

OMB No. XXXX-XXXX
Expiration Date: Date
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 XXXX-XXXX. 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.

Garrett Lee Smith (GLS) National Outcomes Evaluation
State/Tribal Suicide Prevention Program
Training Utilization and Preservation Survey
Consent to Contact Form (Core)
Training ID:



Training Name: ______________________________________________________________________
Date of Training/Today’s Date: __________________________________________________________
As part of the National Outcomes Evaluation of Garrett Lee Smith (GLS) Suicide Prevention Programs, we will
be interviewing individuals who participated in suicide prevention training activities like the one for which you have
signed up. The Training Utilization and Preservation Survey is a telephone survey that will be administered to
participants from a random sample of suicide prevention gatekeeper training programs to collect information
about gatekeeper knowledge, attitudes, and behaviors following their trainings. Your participation in this brief
survey is completely voluntary. Your answers to the survey questions will be kept private, except as otherwise
required by law. Your name will not be linked with the information on your survey. Your name will not be used in
any reports about this evaluation. We are interested in contacting you again within the next 3 to 4 months after
you participated in the training to ask you some questions about what you learned during this training; how you
have used what you learned; and what impact it has had on your identification and referral of youths at risk for
suicide in your community. Findings from the survey will assist in informing SAMHSA (which stands for the Substance
Abuse and Mental Health Services Administration) about suicide prevention activities and training experiences.
The survey will take approximately 20 to 30 minutes and will be conducted over the telephone by a member
of the National Outcomes Evaluation team. If you are selected to participate in the interview, in appreciation
of your time, we will provide you with either a $10 Amazon gift code or we will mail you a $10 money
order.
Are you interested in being contacted about possible participation in the Training Utilization and Preservation
Survey?
 Yes
 No
If you are interested in participating in this important effort, or in learning more about the Training Utilization and
Preservation Survey, please provide your contact information below. If you are selected to participate in the
interview, a member of the National Outcomes Evaluation team will contact you. Participants for the survey will be
randomly selected from a complete list of interested training participants.
39. Name:
40. Cell phone:

State/Tribal TUP-S Consent to Contact (Core)
12/2015

a. Best contact?

62

b. Best time to call?

Training ID:


 Yes

41. Work phone:

42. Home phone:

 No

 AM

 PM

a. Best contact?

b. Best time to call?

 Yes

 AM

 No

a. Best contact?
 Yes

 No

 PM

b. Best time to call?
 AM

 PM

43. Work e-mail:

44. Personal e-mail:

45. Preferred
language for
survey

 English

 Spanish

We would also like to ask you a few questions about your experiences identifying and referring with suicidal youths.
46. Please indicate the primary setting in which you
interact with youths:

47. In the last 12 months have you identified youths
you thought might be at risk for suicide?
d. [IF YES] About how many of those were
identified in the last 12 months?
e. [IF YES] About how many of those were
identified in the last 6 months?
f.

[IF YES] About how many of those were
identified in the last 3 months?

48. In which ZIP code(s) did you identify at-risk
youths? Please include all relevant ZIP codes.

State/Tribal TUP-S Consent to Contact (Core)
12/2015

63

 Education (K-12)
 Substance abuse
 Juvenile
justice/Probation
 Emergency response
 Higher education
(college/university)
 Tribal services/Tribal
government
 Yes
 No

 Child welfare
 Mental health care
 Other community
settings
 Don’t know
 Refused

 None
 Number
identified_______
 None
 Number
identified_______
 None
 Number
identified______

 Don’t know
 Refused

ZIP code 1

ZIP code 3





ZIP code 2

ZIP code 4





 Don’t know
 Refused

 Don’t know
 Refused
 Don’t know
 Refused

Training ID:



IF YES, these questions refer to the most recent occasion when you identified a youth at risk for suicide.
49. Thinking about the youth you identified most
recently, did you ask the youth whether she/he
was considering suicide?

 Yes
 No

 Don’t know
 Refused

50. Thinking about the youth you identified most
recently, did you refer the youth to get further
assistance or support?

 Yes
 No

 Don’t know
 Refused

g. If YES, about how many youths that did you
refer for further assistance or support?

 None
 Don’t know
 Number
 Refused
identified_________
If you have any concerns or questions about your participation in this study, please contact
Christine Walrath, principal investigator, at (212) 941-5555 or [email protected].
Whether you selected yes or no above, please return this page to the training facilitator.
Thank you!

State/Tribal TUP-S Consent to Contact (Core)
12/2015

64