OMB Control Number: 2900-XXXX
Estimated Burden: 15 minutes
Expiration Date: 04/30/2022
DEPARTMENT OF VETERANS AFFAIRS
Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP)
Intake Form
Purpose and Instructions |
The SSG Fox SPGP Intake Form must be used by eligible entities that participate in the SSG Fox Suicide Prevention Program for a one-time capture of an eligible individual’s demographic, Veteran Status, History of Use of VA services and any anticipated challenges that an eligible individual may experience during participation in the program.
Paperwork Reduction Act and Privacy Statement: This information is being collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended to complete this eligibility screening will average 15 minutes. This includes the time needed to follow instructions, gather the necessary facts, and respond to the questions. Any information provided will be kept private to the extent provided by law. Participation in this survey is voluntary, and failure to respond will not have any impact on a participant’s entitlement to benefits.
The form submission deadline for all eligible entities is at or after the first visit with the eligible individual but prior to the next visit. VA intends to review the information from each intake form, which will help VA understand eligible individuals who are participating in the program and what may need to be modified in the program to support those eligible individuals’ needs.
The form must be completed and submitted electronically for each eligible individual associated with the eligible grantee. Additional information for using the online Form will be available upon eligible entity award.
This Form contains the following sections:
Section 1: Demographics
Section 2: Eligible Individual Military History and VA Benefits Review
Section 3. Referral and Previous Suicide Prevention Services
Section 4. Baseline Mental Health Screening
Section 1. Demographics |
Date of Completion [TEXT BOX]
(e.g., MM/DD/YYYY)
First Name [TEXT BOX] Last Name [TEXT BOX] SSN [TEXT BOX]
Date of Birth [MONTH, DAY, YEAR DROP-DOWN]
(e.g., MM/DD/YYYY)
Address [TEXT BOX]
(Full current residential address, include Zip Code)
Phone Number [TEXT BOX]
(xxx-xxx-xxxx)
Age Range:
18-21
22-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-75
76-80
81+
Race (Check all that apply) [CHECK BOX]
American Indian or Alaskan native
Asian
Black/ African American
Caucasian/ White
Hispanic or Latino
Native Hawaiian or Pacific Islander
Multiple Races
Other
Prefer not to answer
Are you of Hispanic, Latino, or Spanish origin? [CHECK BOX]
No, not of Hispanic, Latino, or Spanish origin
Cuban
Mexican, Mexican American
Puerto Rican
Other Hispanic, Latino, or Spanish origin
Please specify: [TEXT BOX]
Sex assigned at Birth [SELECT ONE]
Male Female
Gender Identity (Check all that apply) [CHECK BOX]
Man Woman Non-binary Another gender not described above [TEXT BOX]
Do you identify as transgender? [SELECT ONE]
Yes No Prefer not to answer
Marital Status [SELECT ONE]
Married Domestic Partner Divorced Single, never married Widow/Widower
Section 2. Eligible Individual Military History and VA Benefits Review |
In which branch or branches did you serve? (Please select the parent service for Guard and Reserve personnel)
[CHECK BOX]
Army
Navy
Air Force
Marines
Coast Guard
Space Force
Public Health Service
National Oceanic and Atmospheric Administration
Unknown
In what era did you serve? (Check all that apply) [CHECK BOX]
September 2001 or later
August 1990 to August 2001 (includes Persian Gulf War)
May 1975 to July 1990
Vietnam Era (February 1961 to May 1975)
November 1952 to January 1961
Korean War (July 1950 to October 1954)
January 1947 to June 1950
World War II (December 1941 to December 1946))
Were you discharged or released under conditions other than honorable? [Y/N/NOT SURE]
Yes No Not Sure
Did you sustain any physical or mental disabling injuries during your military service? [Y/N]
Yes No
Have you received VA Service -Connection rating? [Y/N/PENDING]
Yes No Pending
Do you receive compensation from either a disability rating and/or Pension?
Yes No Pending
Are you enrolled in VA Healthcare? [SELECT ONE]
Yes No Pending
If eligible, are you interested in using VA Healthcare?
Yes No Undecided Prefer not to answer
When was your last contact with any VA services (e.g., Healthcare, Financial Benefits, Homeless Services, Vet Center, etc.)? [SELECT ONE]
3 months
6 months
9 months
1 year
More than 1 year
Never
Please indicate which services: [TEXT BOX] or [Drop Down ]
Do you have Health Care insurance?
Yes No
If yes-Type of Health Care Insurance
Insurance through a current or former employer or union (of yours or another family member)
Insurance purchased on the Affordable Care Act Healthcare Exchange (also known as Obamacare)
Medicare, for people 65 and older, or people with certain disabilities
Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
VA (including those who have ever used or enrolled for VA health care)
TRICARE, TRICARE for Life or other military health care
Other
Section 3. Referral and Previous Suicide Prevention Services |
How were you referred to SSG Fox SPGP? [TEXT BOX] or [Drop Down ]
Is your referral to SSG Fox SPGP a result of an outreach event?
Yes No
If Yes, what was the date and location of the outreach event? [TEXT BOX] or [Drop Down ]
Do you have any challenges that may prevent your participation in the program? [Y/N]
Yes No
If yes, please describe: [TEXT BOX]
Have you previously received any of the following suicide prevention services?
Please indicate all that apply:
Referral to Mental Health Care
Education
Emergency Clinical Services
Case Management
Peer support services
VA benefits assistance
Assistance with obtaining and coordinating other benefits provided by the federal government, a state or local government, or an eligible entity (Benefits Coordination)
Assistance with emergent needs relating to health care services, daily living services, personal financial planning and counseling, transportation
Temporary income support services,
Fiduciary and representative payee services,
Legal services
Other: [TEXT BOX]
Section 4. Baseline Mental Health Screening |
Please complete the assessments listed below
Assessment |
Time to Complete |
Socio Economic Status (SES) |
5-10 Minutes |
Patient Health Questionnaire (PHQ-9) |
1-2 Minutes |
Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWS) |
1-2 Minutes |
Generalized Self-Efficacy Scale |
1-2 Minutes |
Interpersonal Support Evaluation List (ISEL-12) |
1-2 Minutes |
VA Form 10-317b 11MHSP
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | MITRE |
| File Modified | 0000-00-00 |
| File Created | 2022-05-03 |