Form 10-317d SSG Fox SPGP - Program Exit Checklist & Assessments

OMB Control Number: 2900-XXXX

Estimated burden: 30 minutes

Expiration Date: 04/30/2025

The Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program

(SSG Fox SPGP)

Program Exit Checklist

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 30 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 program is voluntary, and failure to respond will not have any impact on a participant’s entitlement to benefits.

Purpose

The SSG Fox SPGP Program Exit Checklist must be used by eligible entities that participate in the SSG Fox Suicide Prevention Grant Program for a final capture of assessments for the Baseline Mental Health Screening. SSG Fox SPGP grantees must utilize this checklist to review whether the program carries out the appropriate assessments.

Eligible Individual Identifier: _________________________ Date of Entry/Exit: ____­____ /________

Complete when exit determination has been made:

Exit Overview – Baseline Mental Health Screening Completed
☐ Yes ☐ No	Socio Economic status (SES)
☐ Yes ☐ No	Patient Health Questionnaire (PHQ-9)
☐ Yes ☐ No	Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWS)
☐ Yes ☐ No	Generalized Self-Efficacy Scale
☐ Yes ☐ No	Interpersonal Support Evaluation List (ISEL-12)
☐ Yes ☐ No	Veteran Satisfaction Survey sent

Exited for Other Reasons *To be completed in addition to Exit Overview above
☐ Yes ☐ No ☐ N/A	Case manager has completed steps required by agency policy for these participants: For nonresponsive participants, grantee has attempted contact the specific numbers of times and channels as required by the grantee’s policies and procedures. Other reasons: Please indicate

Exit Summary:

I confirm, to the best of my knowledge, that the above information is correct:

SSG Fox SPGP Staff Signature: ­________________________________________________ Date: _________________

I confirm, to the best of my knowledge, that the above requirements have been completed:

SSG Fox SPGP Supervisor Signature: ____________________________________________ Date: _________________

VA Form 10-317d 11MHSP