0920-0879 Suicide Prevention Web-based Survey - Delegates

Survey Home - State of the State, Territory, and Tribal (S/T/T) Suicide Prevention Survey - draft

State of the State, Territory, and Tribal (S/T/T) Suicide Prevention Survey

Form Approved
OMB No. 0920-0879
Expiration Date 01/31/2021
             This survey is meant for state, tribal, or territorial health department and behavioral health staff, grant managers,
and coalition or advisory group leaders. It will help the Centers for Disease Control and Prevention’s (CDC) Division of
Violence Prevention conduct an environmental scan with all 50 states, Washington D.C., US territories and select tribes to
understand how suicide prevention is addressed, now, and in the past five years.
Your feedback is important to us and will help CDC’s Division of Violence Prevention to improve suicide prevention technical
assistance to states, territories, and tribes and develop recommendations to improve public health response to prevent
suicide.
              When you see “S/T/T”, this refers to you if you are a representative of a state, Washington, DC, territory, or tribe.
 Completing the questionnaire is voluntary and takes approximately 30 minutes.  CDC will not publish or share any
identifying information about individual respondents. Data collected from this survey will be reported only in aggregate
form. There are no known risks or direct benefits to you from participating or choosing not to participate, but your answers
will help CDC improve state, tribal and territorial suicide prevention.
As you complete the survey, you may find that you need to gather some information from your records. Also, you are able
to move forward and backwards in the survey. You are able to exit the survey and return to complete it.
If you have any questions or concerns about this assessment, please contact Doryn Chervin ([email protected]) or
Doriane Sewell ([email protected]).
        CDC estimates the average public reporting burden for this collection of information as 30 minutes per response,
including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the
data/information needed, and completing and reviewing the collection of information.  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. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS
D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).

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Please save this pass code in
reference to your survey response.

Begin Survey
Begin
Survey
Survey Starting Date: Monday, May 7, 2018 12:00 AM
Survey Closing Date: Thursday, May 31, 2018 11:59 PM

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