10-317b SSG Fox SPGP - Intake Form & Assessments

Staff Sergeant Parker Gordon Fox - Suicide Prevention Grant Program (SSG Fox SPGP)

SSG Fox SPGP_Intake Form_10-317b_Final

OMB: 2900-0904

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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

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