OMB Number:
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 0930-0286. Public reporting burden for this collection of information is estimated to average 3 hours 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.
PREVENTION STRATEGIES INVENTORY (PSI)
Strategy/Activity or Product Descriptions
OUTREACH AND AWARENESS Public Awareness Campaigns Public awareness campaigns are organized systematic efforts using multiple communications media to make the general public or a particular target population aware of key messages about suicide prevention. *Please note: campaigns that are specific to means restriction should be reported under “Means Restriction Awareness Campaigns.” Examples of public awareness campaigns are: the “Be Well to Do Well (BW2DW)” mental health awareness campaign; the “I Am Not a Bystander” campaign; the “How YOU Doin’” campaign; the “Suicide Shouldn’t Be a Secret” campaign; the “Ask, Listen, Refer” campaign; and the “Don't Erase Your Future” campaign. Outreach and Awareness Activities/Events These are activities and events intended to promote awareness about suicide prevention and are not connected to a particular public awareness campaign. *Please note: activities/events specific to means restriction should be reported under “Means Restriction Activities and Events.” Examples of outreach and awareness activities/events are: a suicide prevention poster contest, an “Out of Darkness” walk, a booth at a health fair, suicide awareness day, and events held during National Red Ribbon Week. Outreach and Awareness Products These are products intended to promote awareness about suicide prevention. Their distribution is not limited to or connected to a particular public awareness campaign or to a particular activity/event. *Please note: products specific to means restriction should be reported under “Means Restriction Products.” Examples of outreach and awareness products are: radio and TV public service announcements; website development or enhancement; newspaper articles; billboards; and awareness products such as stress balls, mood pens, T-shirts, and bracelets. GATEKEEPER TRAINING School-Based Adult School-based gatekeeper training programs are trainings designed to help school staff identify students at risk of suicide and to refer them for help. School adult gatekeepers may include any adult in the school (e.g., counselors, teachers, coaches, administrators or cafeteria staff and other school-based staff and volunteers) in a position to observe and interact with students. Example: ASIST training for teachers. School-Based Peer School-based peer gatekeeper training programs are trainings designed to help students identify peers at risk of suicide and refer them for help. These programs may be targeted to all students in middle school or high school or a particular grade. Some programs may also be targeted toward selected “peer helpers,” who are usually selected through a process (by self, peers, teachers, counselors, etc.). Examples of programs to be included here are: Signs of Suicide (SOS), Lifelines, natural helpers program etc. Community Adult Community adult gatekeeper training programs are intended to train adult community members to identify young people at risk of suicidal behaviors and to refer them to appropriate sources of help. This "gatekeeping" function can be undertaken by anyone who has significant contact with youth in the course of professional or volunteer activities. Examples of gatekeepers include coaches, clergy, police officers, health care professionals, emergency medical services personnel, hairdressers and barbers, nurses, primary care physicians and other traditional caregivers. Example: QPR training for police officers. Community Peer Peer gatekeeper training programs are intended to train youth to become “helpers” for other youth within their own peer groups. They are trained to identify peers at risk of suicidal behaviors and refer them to appropriate sources of help. Any youth may function as a peer gatekeeper—tribal youth council members, natural helpers, or veterans. *Please note that if you are training youth in a school setting, select “School-based peer gatekeeper training.” If you are training youth in non-school settings, select “Community Peer Gatekeeper training.” ASSESSMENT, CLINICAL, AND REFERRAL TRAINING For Mental Health Professionals This category refers to training mental health professionals on assessing, managing, and treating suicide risk and making appropriate referrals. Examples of these types of trainings are: Assessing and Managing Suicide Risk (AMSR) for mental health professionals and training clinicians in suicide assessment. For Hotline Staff This category refers to training hotline staff in suicide risk assessment and referral skills. These trainings are generally gatekeeper trainings but must have the specific goal of training those who will be staffing a hotline or helpline. LIFE SKILLS AND WELLNESS DEVELOPMENT Life Skills Development for Youth Curricula These curricula aim to teach children and adolescents the social competencies and life skills needed to support positive social, emotional, and academic development. These life skills include communication, problem solving, depression and stress management, anger regulation, and goal setting. For example, the American Indian Life Skills Development Curriculum covers the following topics: building self-esteem; identifying feelings, emotions, and life stressors; developing effective communication and problem-solving skills; recognizing and eliminating self-destructive behavior; exploring reasons why people attempt suicide; identifying ways to help friends who are considering suicide; and planning for the future. Cultural Activities Activities that use a “culture as prevention” approach and are intended to strengthen the cultural identity of youth in order to provide them with a feeling of security, a sense of belonging and hope for the future. Examples of activities that would fall under this category are: culture camps where youth learn about their traditions, history and languages; recreational activities such as canoe trips, maze and high rope; activities to teach youth traditional arts and crafts; youth drumming and dancing events; and community events such as ceremonies and feasts. Wellness Activities These activities include workshops, educational seminars, speaking events, and trainings that provide students with essential life skills and promote wellness. These activities are intended to support positive social, emotional, spiritual, and academic development. Examples of Life Skills and Wellness Activities are: workshops on stress management or healthy relationships; seminars on depression, anxiety, eating disorders and body image; tai chi; yoga; meditation; progressive muscle relaxation; and dance and movement. SCREENING PROGRAMS Early Identification Screening Programs involve the administration of a screening instrument or an online mental health screening tool to identify at-risk youth. Examples of Screening Programs include: depression screening, ISP, other online screening tools. HOTLINES, HELPLINES, TEXTLINES, AND CHATLINES Hotlines and Helplines Developing, maintaining, or supporting hotline or helpline services for the community. For example, a grantee may use GLS funds to develop and maintain a hotline service for LGBTQ+ youth or a grantee can use funds to develop a local call center for the National Suicide Prevention Lifeline. *Please note: training for hotline staff should be indicated under “Assessment and Referral Training for Hotline Staff.” Also, materials promoting the National Suicide Prevention Lifeline should be reported under “Outreach and Awareness Products.” Textlines and Chatlines Developing, maintaining, or supporting text or web-based chat support services for the community. *Please
note: training for text and chat staff should be indicated under
“Assessment and Referral Training for Hotline Staff”
and materials promoting the textline, chatline, or National
Suicide Prevention Lifeline should be reported under “Outreach
and Awareness Products.” Means restriction are efforts that aim to educate about the issue of lethal means restriction. Examples of efforts that would be reported under this category include: a campaign dedicated to reducing access to lethal means, and outreach and awareness events, activities and materials focused on issues related to access to lethal means. Means Restriction Public Awareness Campaigns A means public awareness campaign is an organized systematic effort through various communications media focused on creating awareness about access to lethal means among the general public or particular target populations. For example: the “Lock ‘Em Up” Prescription Drug Campaign. Distribution of Gun Locks and Lock Boxes This refers to distribution of gun locks locks for gun cabinets and lockboxes that can store items such as medicines, ammunition, and knives. Means Restriction Activities and Events Events or activities intended to promote awareness about access to lethal means but not connected to a particular public awareness campaign. Means Restriction Products Products intended to promote awareness about access to lethal means and not connected to a particular public awareness campaign. Examples of these types of products are: radio and TV public service announcements, website development or enhancement, newspaper articles, brochures, billboards, and awareness products such as stress balls, mood pens, T-shirts, and bracelets. Means Restriction Training Training designed to teach behavioral health professionals to counsel the families of those at-risk for suicide in methods to reduce access to lethal means. Lethal Means Counseling Assessing the access an at-risk youth has to lethal means and counseling their family to restrict access to these lethal means while the youth is at-risk. POLICIES,
PROTOCOLS, AND INFRASTRUCTURE Policies and Protocols Related to Intervention Policies and protocols related to intervention guide the actions of all agencies and personnel involved in ensuring that at-risk students receive coordinated, timely and effective assessment, referral, treatment, and follow-up support. Policies and Protocols Related to Postvention Policies and protocols related to postvention guide the actions of all agencies and staff involved in taking appropriate postvention steps to support family, friends, and other community members following a suicide, and to prevent cluster suicides. Electronic Health Record Implementation and Utilization The
implementation or utilization of electronic health records to
align with suicide prevention efforts, such as tracking follow-up
services or referrals, enhancing communications, or improving
surveillance. The participating agencies, programs, or organizations in suicide prevention or other prevention coalitions are examples of partnerships. This category also includes partnerships that result in coordinated services or activities. Leading or Substantially Supporting a Suicide Prevention Coalition The development of a means for cooperation and collaboration among persons, groups, or organizations to work together toward goals related to suicide prevention. Leading or Substantially Supporting a Coalition That Is Closely Related to Youth Suicide Prevention The development of a structured arrangement for cooperation and collaboration among persons, groups, or organizations, in order to work together toward goals related to youth prevention (e.g., youth violence, substance abuse) or the promotion of health and well-being. Participating In Coalitions Related to Youth Prevention Participation in or support of coalitions related to prevention efforts (e.g., youth violence, domestic violence, or substance abuse) or the promotion of mental health and well-being. Partnerships with Agencies and Organizations Efforts to build partnerships to facilitate timely, effective and coordinated suicide prevention and early identification. These partnerships will generally involve a memorandum of understanding or other formal agreement. DIRECT SERVICES AND TRADITIONAL HEALING PRACTICES Mental Health-Related Services Mental health-related services that are provided or supported by a grantee’s suicide prevention program. Examples of potential mental health-related services are: assessment services (e.g., a clinical assessment resulting from an early identification activity or referral); counseling services; and family support services. Postvention Services Services that are provided or supported by a grantee’s suicide prevention program after a suicide attempt or a death by suicide, largely taking the form of support for the bereaved (i.e., family, friends, professionals, and peers). Examples of postvention services include: Family support services; community support services; group or individual support services; and peer support groups. Case Management Services Case management services are provided or supported by a grantee’s suicide prevention program. Services include assessing the needs of the at risk youth and his or her family, and arranging, coordinating, monitoring, evaluating, and advocating for a package of multiple services to meet the youth’s specific needs. Crisis Response Services Emergency services such as crisis response services or mobile response services are provided or supported by a grantee’s suicide prevention program. Traditional Healing Practices This category refers to traditional healing practices grounded in Native history and culture which help individuals move toward a state of mental well-being. These may include practices such as sweat lodge ceremonies, talking circles in response to a crisis, spiritual ceremonies and other cultural practices that support healing and recovery. Follow-Up Services This category refers to efforts focused on ensuring that youth receive appropriate services following identification, such as follow-up phone calls or reminders. CARE TRANSITIONS Caring Contacts After Emergency Department Discharge This category refers to reach out to youth following discharge from the Emergency Department to provide a supportive or caring contact for the purpose of expressing care or concern for the youth. Follow Up After Emergency Department Discharge This category refers to efforts focused on ensuring youth receive appropriate follow-up services following discharge from an Emergency Department. Caring Contacts After Inpatient Hospitalization This category refers to reach out to youth following discharge from inpatient hospitalization to provide a supportive or caring contact for the purpose of expressing care or concern for the youth. Follow Up After Inpatient Hospitalization This category refers to efforts focused on ensuring youth receive appropriate follow-up services following discharge from inpatient hospitalization. OTHER SUICIDE PREVENTION STRATEGIES Prevention strategies that cannot be classified under the previously listed strategy types can go under “Other.” Items that are commonly reported in this strategy include: other trainings (e.g., cultural competence/SafeZone trainings), congressional testimony/advocacy, postvention activities or products, or work to make suicide prevention education part of a course curriculum or degree requirement. |
The PSI provides quarterly reporting of strategies and sub-strategies implemented by each grantee and includes 13 strategies and 37 related sub-strategies as indicated in the table below. Grantees will respond to a set of similar questions related to each sub-strategy that they have implemented during the relevant quarter.
|
Strategy |
Sub-strategy |
1. |
Outreach and Awareness |
Public awareness campaigns |
Outreach and awareness activities and events |
||
Outreach and awareness products |
||
2. |
Gatekeeper Training |
School-based adult gatekeeper training |
School-based peer gatekeeper training |
||
Community-based adult gatekeeper training |
||
Community-based peer gatekeeper training |
||
3. |
Assessment, Clinical, and Referral Training for Mental Health Professionals and Hotline Staff |
Mental health professionals |
Hotline staff |
||
4. |
Life Skills and Wellness Development |
Life skills development for youth curricula |
Cultural activities |
||
Wellness activities |
||
5. |
Screening Programs |
N/A |
6. |
Hotlines, Helplines, Textlines, and Chatlines |
Hotlines and helplines |
Textlines and chatlines |
||
7. |
Means Restriction |
Means restriction public awareness campaign |
Distribution of gun locks and lock boxes |
||
Means restriction activities and events |
||
Means restriction products |
||
Means restriction training |
||
Lethal means counseling |
||
8. |
Policies, Protocols, and Infrastructure |
Policies and protocols related to intervention |
Policies and protocols related to postvention |
||
Electronic health record implementation and/or utilization |
||
9. |
Coalitions and Partnerships |
Leading or substantially supporting a suicide prevention coalition |
Leading or substantially supporting a coalition that is closely related to youth suicide prevention |
||
Participating in coalitions related to youth suicide prevention |
||
Partnership with agencies and organizations |
||
10. |
Direct Services and Traditional Healing Practices |
Mental health-related services |
Postvention services |
||
Case management services |
||
Crisis response services |
||
Follow-up services |
||
11. |
Traditional Healing Practices |
N/A |
12. |
Care Transitions |
Follow-up after emergency department discharge |
Follow-up after inpatient hospitalization |
||
13. |
Other Suicide Prevention Strategies |
|
In addition to completing the quarterly PSI, grantees will complete two additional PSI modules focused on the following topics: 1) efforts to promote behavioral health equity as part of their strategy implementation and 2) plans for sustaining grantees’ strategies and program overall. These modules are described further below, followed by tables listing the questions included in the quarterly PSI.
This module is designed to assess grantee efforts to reduce behavioral health disparities and promote behavioral health equity as part of their strategy implementation. Questions focus on cultural adaptations, efforts to address social determinants of health, progress, and lessons learned. This module will be administered annually directly following grantees’ submission of the PSI in Quarter 4. The SPDC will generate a list of the strategies and sub-strategies that grantees have entered throughout the year (in Q1, Q2, Q3, and Q4) for reference. Grantee staff completing the PSI will be prompted to consider the list of strategies and respond to several questions with broad consideration of strategy implementation over the year (Questions 1-3 listed in the table below). In addition, grantees will be asked to respond to strategy-specific questions as relevant to their project implementation over the year (Questions 4-5 below).
BEHAVIORAL HEALTH EQUITY: ALL STRATEGIES |
|||
Q Num |
Question |
Response Options |
|
1. |
What steps have you taken to reduce behavioral health disparities and advance health equity for populations served through your program? Select all that apply.
Definitions* |
Community perspectives on program design/implementation
Staffing and advisory board
Language and literacy
Implementation focus
Other
|
|
2. |
Based on your selections in question 1, please provide one or more stories illustrating program implementation progress related to decreasing behavioral health disparities and promoting behavioral health equity in communities underserved by the behavioral health system. Please focus on key program highlights or examples. |
(Open-ended) |
|
3. |
Based on your selections in question 1, please provide one or more stories illustrating lessons learned related to decreasing behavioral health disparities and promoting behavioral health equity through related practices. Please focus on key program highlights or examples. |
(Open-ended) |
|
* DEFINITIONS: Health Disparities: A particular type of difference that is closely linked with social, economic, environmental disadvantage, and/or other characteristics historically linked to systemic barriers or exclusion. Health disparities adversely affect groups of people who may have systematically or historically experienced greater obstacles to well-being (Disparity Impact Statement 101, SAMHSA, August 2022, https://www.samhsa.gov/sites/default/files/dis-training-slides.pdf). Among other examples, health disparities contribute to disproportionate rates of suicidal thoughts, plans, attempts, and deaths among vulnerable populations. Behavioral Health Equity: The right to access high-quality and affordable health care services and supports for all populations regardless of the individual’s race, age, ethnicity, gender (including gender identity), disability, socioeconomic status, sexual orientation, or geographic location. Advancing behavioral health equity involves ensuring that everyone has a fair and just opportunity to be as healthy as possible (SAMHSA, Behavioral Health Equity, July 2022, https://www.samhsa.gov/behavioral-health-equity). Social Determinants of Health: The conditions in the environment where people are born, live, work, play, worship, age and thrive that affect a wide range of health, functioning, and quality-of-life outcomes and risks (Healthy People 2030, https://health.gov/healthypeople/priority-areas/social-determinants-health; Centers of Disease Control and Prevention, Social Determinants of Health, December 2022: https://www.cdc.gov/about/sdoh/index.html).
BEHAVIORAL HEALTH EQUITY: STRATEGY-SPECIFIC QUESTIONS |
|||
Q Num |
Question |
Response Options |
|
4. |
In considering the types of strategies your program has implemented over the year, please select any strategy types that have involved adapting related activities or materials to meet the specific needs of the intended audience/ population of focus.
Grantees will review a list of strategies they reported implementing over the year based on the quarterly PSI.
|
(No response options) |
|
4a. |
Please indicate the types of adaptations made to the content or delivery of activities included as part of this strategy to meet the needs of the intended audience/populations of focus. Select all that apply.
Grantees will respond to this question related to each strategy they select in response to Question 4.
|
|
|
5. |
In considering the types of strategies your program has implemented over the year, please select any strategy types that have included activities or materials designed to address specific social determinants of health (SDoH) relevant to the communities served by your program.
SDoH are the conditions in the environment where people are born, live, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.1
Grantees will review a list of strategies implemented over the year based on the quarterly PSI and select strategies including activities or sub-strategies designed to address community specific SDoH.
|
(No response options) |
|
5a. |
Please select the SDoH addressed through implementation of (display strategy title). Select all that apply.
|
|
|
5b. |
Please provide a description of how the SDoH have been addressed through implementation of (display strategy title).
|
(Open-ended) |
|
This module is designed to assess grantee progress related to planning for sustainability and is designed to be completed by grantees twice during the grant period: 1) in the early stages of program development, and 2) in the later stages of grant implementation. For currently funded grantees, this module will be administered in Quarter 1 of Fiscal Year 2025 (all grantees) and again in Quarter 3 of Fiscal Year 2027 (Cohort 17 grantees only). Any newly funded grantees will participate in this module in Quarter 1 of the first year of the grant and in Quarter 3 of the last year of the grant. In each case, the SPDC will generate a list of the strategies and sub-strategies grantees have reported implementing in the quarterly PSI for reference. Grantee staff will respond to one strategy-specific question at each administration timepoint and a larger set of questions regarding program sustainability overall at the second administration timepoint. Questions included in each administration are listed below.
First Administration
Instruction: For the following question, please consider this strategy specifically and select one response option. (The system will prompt a response for each strategy type implemented by the grantee).
SUSTAINABILITY: STRATEGY-SPECIFIC QUESTION |
||
Q Num |
Question |
Response Options |
1. |
What are your plans for sustaining the activities you have implemented as part of this strategy after the end of the GLS State/Tribal grant funding period? Please select one of the following.
|
|
Second Administration
Instruction: For the following question, please consider this strategy specifically and select one response option. (The system will prompt a response for each strategy type implemented by the grantee).
SUSTAINABILITY: STRATEGY-SPECIFIC QUESTION |
||
Q Num |
Question |
Response Options |
1. |
What are your plans for sustaining the activities you have implemented as part of this strategy after the end of the GLS State/Tribal grant funding period? Please select one of the following.
|
|
Instruction: For the following questions, please consider your program overall and select the number that best indicates the extent to which your program has or does the following things.
SUSTAINABILITY: OVERALL PROGRAM IMPLEMENTATION (ALL STRATEGIES)3 |
|||||||||
Q Num |
|
Response Options |
|||||||
|
|
To little or no extent |
|
|
|
|
|
To a very great extent |
Not able to answer |
2. |
The program has strong champions with the ability to garner resources. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
3. |
The program is funded through a variety of sources. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
4. |
The community is engaged in the development of program goals. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
5. |
Diverse community organizations and agencies are invested in the success of the program. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
6. |
Community leaders are involved with the program. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
7. |
Plans are in place to continue existing partnerships with organizations and agencies. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
8. |
Organization and agency partnerships are important to support program continuation. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
9. |
The program is well integrated into the operations of the organization. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
10. |
Leadership efficiently articulates the vision of the program to external partners. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
11. |
The program has adequate staff to complete the program’s goals. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
12. |
Program evaluation results are used to demonstrate successes to funders and others. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
13. |
The program proactively adapts to changes in the environment and new science. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
14. |
The program has communication strategies to secure and maintain public support. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
15. |
The program plans for future resource needs. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
N/A |
Instruction: For the following questions, please consider your program overall and select the best response option.
SUSTAINABILITY: OVERALL PROGRAM IMPLEMENTATION (ALL STRATEGIES) |
||
Q Num |
Question |
Response Options |
16. |
What external systems and supports will your program rely on to help sustain program goals and activities? Select all that apply.
|
SAMHSA grants__ Other Federal grants__ State__ Local__ Organization/nonprofit__ Other__
|
17. |
[IF PARTNERSHIP RESPONSE OPTIONS ARE SELECTED IN 16] Please describe the types of partnerships that are most important to the implementation of your program and how your program will be sustained through ongoing partnerships. |
(Open-ended) |
18. |
[IF A RESPONSE OPTION RELATED TO OTHER IS SELECTED] Please indicate how multiple types of grants (suicide prevention or other) work together to achieve suicide prevention program goals. Select all that apply. |
(Include multiple “Other” fields as needed) |
As noted, the quarterly PSI includes 13 strategies and 37 related sub-strategies (see overview table in the prior section). Grantees will complete the following each quarter:
Sub-strategy-related questions: Grantees will respond to a set of questions related to each sub-strategy they have implemented during the relevant quarter (these questions are listed in the following section).
General question: At the end of the PSI each quarter, the grantee will respond to a final question focused on strategy implementation related to the goals of the National Strategy for Suicide Prevention (NSSP). This question is listed below:
NATIONAL STRATEGY FOR SUICIDE PREVENTION: GENERAL QUESTION |
||
Q Num |
Question |
Response Options |
1. |
With consideration of all strategies and activities implemented through your program in this quarter, which components of the National Strategy for Suicide Prevention (NSSP) has your program addressed? Please select all that apply (in part or in whole).
|
|
STRATEGY 1: OUTREACH AND AWARENESS |
||
Public Awareness Campaigns |
||
Q Num |
Question
|
Response Options
|
1 |
What is the name of the public awareness campaign? |
|
2 |
Please indicate the date(s) of the public awareness campaign implementation. Select the most specific date as relevant to the campaign. |
|
3 |
Please indicate the location of intended audiences for the public awareness campaign. Select the most specific location as relevant to the campaign. |
|
4 |
Please describe the public awareness campaign including goals and intended audiences. |
|
5 |
Is the public awareness campaign intended for the general population (i.e., the entire community)? |
|
6 |
If no, please indicate the primary intended audience for the public awareness campaign. Choose only one response. |
|
7 |
Please indicate any additional intended audiences for the public awareness campaign. Select all that apply. |
|
8 |
Does your campaign place emphasis or focus on any of these populations at high risk for suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
9 |
Please indicate which of the following elements are used in this public awareness campaign. |
|
10 |
Was this campaign implemented as intended based on your work plan? |
Please explain: __________________________ |
Outreach and Awareness Activities and Events |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the activity or event? |
|
|
2 |
Please indicate the date(s) of the activity/event. Select the most specific date relevant for this activity/event. |
|
|
3 |
Please indicate the location(s) of the activity/event. Select the most specific location relevant for this activity/event. |
|
|
4 |
Type of activity/event |
|
|
5 |
Please describe the activity or event. Explain how the activity or event relates to the goals of your suicide prevention program. |
|
|
6 |
Please describe the intended audience for the activity/event. |
|
|
7 |
Does the activity or event involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
8 |
Is the activity or event intended for the general population (i.e., the entire community)? |
|
|
9 |
If no, please indicate the primary population of focus for this activity or event. Choose only one response. |
|
|
10 |
Please indicate any additional populations of focus for the activity or event. Select all that apply. |
|
|
11 |
Does this activity/event place emphasis or focus on any of these populations at high risk for suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
12 |
Was this activity or event implemented as intended based on your work plan? |
Please explain: __________________________ |
|
Outreach and Awareness Products |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of product? |
|
|
2 |
Please indicate the date(s) when the product was developed or disseminated. Select the most specific date as relevant for this product. |
|
|
3 |
Please indicate the location(s) of the intended audience for this product. Select the most specific location as relevant. |
|
|
4 |
Type of product |
|
|
5 |
Please describe the product. Explain how this product relates to the goals of your suicide prevention program. |
|
|
6 |
Please describe the intended audience for this product. |
|
|
7 |
Is the product intended for the general population (i.e., the entire community)? |
|
|
8 |
If no, please indicate the primary population of focus for the product. Choose only one response. |
|
|
9 |
Please indicate any additional populations of focus for the product. Select all that apply. |
|
|
10 |
Does this product place emphasis or focus on any of these populations at high risk for suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
11 |
Does the product or its dissemination involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
12 |
Was this product produced and/or disseminated as intended based on your work plan? |
|
|
STRATEGY 2: GATEKEEPER TRAINING |
|||
School-Based Adult Gatekeeper Training |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the training? |
|
|
2 |
Please indicate the date(s) of the training implementation. Select the most specific date as relevant for this training approach. |
|
|
3 |
Please indicate the delivery method for the training. |
|
|
4 |
Please indicate the type of training: |
[IF OTHER] Is this a locally developed training?
|
|
5 |
Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
6 |
Were the trainees members of the general population (i.e., the entire community)? |
|
|
7 |
If no, please indicate the types of trainees. Select all that apply. |
|
|
8 |
Does this training place emphasis or focus on any of these populations at high risk for suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
9 |
Please describe the training. Include information such as: why this training type has been selected for this group of trainees and how the training has been adapted to meet the needs of the trainees. If you are using a locally developed curriculum, please also describe the content of the curriculum. |
|
|
10 |
Was this training implemented as intended based on your work plan? |
Please explain: __________________________ |
|
11 |
How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? Select all that apply. |
|
|
12 |
What practices or protocols are in place to follow-up with youth who do not receive a mental health service (or other support services) within three months of referral? Select all that apply. |
|
|
School-Based Peer Gatekeeper Training |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the training? |
|
|
2 |
Please indicate the date(s) of the training implementation. Select the most specific date as relevant for this training approach. |
|
|
3 |
Please indicate the delivery method for the training. |
|
|
4 |
Please indicate the type of training. |
[IF OTHER] Is this a locally developed training?
|
|
5 |
Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
Please describe technology used_____________
|
|
6 |
Were the trainees members of the general population (i.e., the entire community)? |
|
|
7 |
If no, please indicate the types of trainees. Select all that apply. |
|
|
8 |
Does this training place emphasis or focus on any of these current priority populations at high risk for suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
9 |
Please describe the training. Include information such as: why this training type has been selected for this group of trainees and how the training has been adapted to meet the needs of this group of trainees. If you are using a locally developed curriculum, please also describe the content of the curriculum. |
|
|
10 |
Was this training implemented as intended based on your work plan? |
Please explain: __________________________ |
|
11 |
How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? Select all that apply. |
|
|
12 |
What practices or protocols are in place to follow-up with youth who do not receive a mental health service (or other support services) within three months of referral? Select all that apply. |
|
|
Community-based Adult Gatekeeper Training |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the training? |
|
|
2 |
Please indicate the date(s) of the training implementation. Select the most specific date as relevant for this training approach. |
|
|
3 |
Please indicate the delivery method for the training. |
|
|
4 |
Please indicate the type of training: |
[IF OTHER] Is this a locally developed training?
|
|
5 |
Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
6 |
Were the trainees members of the general population (i.e., the entire community)? |
|
|
7 |
If no, please indicate the types of trainees. Select all that apply. |
|
|
8 |
Does this training place emphasis or focus on any of these current priority populations? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
9 |
Please describe the training. Include information such as: why this training type has been selected for this group of trainees and how the training has been adapted to meet the needs of this group of trainees. If you are using a locally developed curriculum, please also describe the content of the curriculum. |
|
|
10 |
Was this training implemented as intended based on your work plan? |
Please explain: __________________________ |
|
11 |
How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? Select all that apply. |
|
|
12 |
What practices or protocols are in place to follow-up with youth who do not receive a mental health service (or other support services) within three months of referral? Select all that apply. |
|
|
Community-based Peer Gatekeeper Training |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the training? |
|
|
2 |
Please indicate the date(s) of the training implementation. Select the most specific date as relevant for this training approach. |
|
|
3 |
Please indicate the delivery method for the training. |
|
|
4 |
Please indicate the type of training. |
[IF OTHER] Is this a locally developed training?
|
|
5 |
Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
Please describe technology used_____________
|
|
6 |
Were the trainees members of the general population (i.e., the entire community)? |
|
|
7 |
If no, please describe the youth who are being targeted. |
|
|
8 |
Does this training place emphasis or focus on any of these populations at high risk of suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
9 |
Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; and strategies for recruiting participants. If you are using a locally developed curriculum, please also describe the content of the curriculum. |
|
|
10 |
Was this training implemented as intended based on your work plan? |
Please explain: __________________________ |
|
11 |
How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? Select all that apply. |
|
|
12 |
What practices or protocols are in place to follow-up with youth who do not receive a mental health service (or other support services) within three months of referral? Select all that apply. |
|
|
STRATEGY 3. ASSESSMENT, CLINICAL, AND REFERRAL TRAINING FOR MENTAL HEALTH PROFESSIONALS AND HOTLINE STAFF |
||||
Mental Health Professionals |
||||
Q Num |
Question
|
Response Options
|
|
|
1 |
What is the name of the training? |
|
|
|
2 |
Please indicate the date(s) of the training implementation. Select the most specific date as relevant for this training approach |
|
|
|
3 |
Please indicate the delivery method for the training. |
|
|
|
4 |
Please indicate the type of training: |
[IF OTHER] Is this a locally developed training?
|
|
|
5 |
Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
|
6 |
Please indicate the types of trainees. |
|
|
|
7 |
Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; and strategies for recruiting participants. If you are using a locally developed curriculum, please also describe the content of the curriculum. |
|
|
|
8 |
Was this training implemented as intended based on your work plan? |
Please explain: __________________________ |
|
|
9 |
How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? Select all that apply. |
|
|
|
10 |
What practices or protocols are in place to follow-up with youth who do not receive a mental health service (or other support services) within three months of referral? Select all that apply. |
|
|
|
Hotline Staff |
||||
Q Num |
Question |
Response Options
|
|
|
1 |
What is the name of the training? |
|
|
|
2 |
Please indicate the date(s) of the training implementation. Select the most specific date as relevant for this training approach |
|
|
|
3 |
Please indicate the delivery method for the training. |
|
|
|
4 |
Please indicate the type of training: |
[IF OTHER] Is this a locally developed training?
|
|
|
5 |
Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
|
6 |
Please indicate the types of trainees. |
|
|
|
7 |
Please describe the training. Include information such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; and strategies for recruiting participants. If you are using a locally developed curriculum, please also describe the content of the curriculum. |
|
|
|
8 |
Was this training implemented as intended based on your work plan? |
Please explain: __________________________ |
|
|
STRATEGY 4. LIFE SKILLS AND WELLNESS DEVELOPMENT |
|||
Life Skills Development for Youth Curricula |
|||
Q Num |
Question |
Response Options |
|
1 |
What is the name of the curriculum? |
|
|
2 |
Please indicate the date(s) when you have used this curriculum. Select the most specific date as relevant for this curriculum. |
|
|
3 |
Please indicate the delivery method for the curriculum. |
|
|
4 |
[IF THE CURRICULUM WAS USED IN PERSON OR VIRTUALLY FROM A CENTRAL LOCATION] Please list the implementation location. Select the most specific location as relevant. |
|
|
5 |
Type of curriculum.
|
[IF OTHER] Is this a locally developed training?
|
|
6 |
Does the curriculum involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
7 |
Please describe the youth who are the intended audience for this curriculum (age group, demographics) |
|
|
8 |
Does this life skills development strategy place emphasis or focus on any of these populations at high risk of suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
9 |
Please describe the curriculum. Include information such as: why this particular curriculum type has been selected; how the curriculum has been adapted to meet the needs of this group; and strategies for recruiting participants. If you are using a locally developed curriculum, please also describe the content of the curriculum. |
|
|
10 |
Was this curriculum implemented as intended based on your work plan? |
Please explain: __________________________ |
|
Cultural Activities |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the activity? |
|
|
2 |
Please indicate the date(s) when the cultural activities were implemented. Select the most specific date as relevant for this cultural activity. |
|
|
3 |
Please indicate the location(s) where the cultural activities were implemented. Select the most specific location as relevant for this cultural activity. |
|
|
4 |
Type of activity.
|
|
|
5 |
Please describe the activity. |
|
|
6 |
Does the activity involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
7 |
Please describe the youth who are the audience for the cultural activities (age group, demographics). |
|
|
8 |
Does this cultural activity place emphasis or focus on any of these populations at high risk of suicide? Select all that apply. |
[If
selected] Are youth connected to school or
|
|
9 |
Were the cultural activities implemented as intended based on your work plan? |
|
|
Wellness Activities |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the activity? |
|
|
2 |
Please indicate the date(s) the activities were implemented. Select the most specific date as relevant for these activities. |
|
|
3 |
Please indicate the location(s) where the activities were implemented. Select the most specific location as relevant to these activities. |
|
|
4 |
Please describe the activity or activities including the purpose and relationship to suicide prevention efforts. |
|
|
5 |
Does the activity involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
No |
|
6 |
Does this wellness activity place emphasis or focus on any of these populations at high risk for suicide? Select all that apply. |
[If
selected] Are youth connected to school or
|
|
7 |
Was this wellness activity implemented as intended based on your work plan? |
|
|
STRATEGY 5. SCREENING PROGRAMS |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the screening program? |
|
|
2 |
Please indicate the date(s) of screening program implementation. Select the most specific date(s) as relevant for this screening program. |
|
|
3 |
Please indicate the location(s) of the screening program implementation. Select the most specific location(s) as relevant for this screening program. |
|
|
4 |
Please indicate the type of screening tool: |
[IF
OTHER] Is this a locally developed screening
|
|
5 |
Please describe the screening program. |
|
|
6 |
Does the screening program involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
7 |
Please indicate the settings that are the focus of the screening program. Select all that apply. |
|
|
8 |
What procedures or processes are in place to ensure that youth, identified as at-risk through this screening tool receive follow-up services within three months of referral? Select all that apply. |
|
|
9 |
How do you monitor or track youth after referral to ensure follow-up services (mental health or other support services) are received? Select all that apply. |
|
|
10 |
What practices or protocols are in place to follow-up with youth who do not receive a mental health service (or other support service) within three months of referral? Select all that apply. |
|
|
STRATEGY 6. HOTLINES, HELPLINES, TEXTLINES, AND CHATLINES |
|||
Hotlines and Helplines |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the hotline/helpline? |
|
|
2 |
Please indicate the date(s) of implementation of the hotline/helpline services. Select the most specific date as relevant for this hotline/helpline service. |
|
|
3 |
Please indicate the intended location for the hotline/helpline. Select the most specific location(s) as relevant for this hotline/helpline service. |
|
|
4 |
Please describe the hotline/helpline. Include information such as whether it is locally developed, hours of function, and whether it is open to the entire community. |
|
|
5 |
Does the hotline/helpline involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
6 |
Please indicate the populations of focus for the hotline/helpline (geographic scope, demographics). |
|
|
7 |
Was this hotline or helpline implemented as intended based on your work plan? |
Please explain: __________________________ |
|
Textlines and Chatlines |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the text/chatline? |
|
|
2 |
Please indicate the date(s) of implementation of the text/chatline. Select the most specific date as relevant to the implementation approach. |
|
|
3 |
Please indicate the location of the intended audiences for the text/chatline. Select the most specific location(s) as relevant to the implementation approach. |
|
|
4 |
Please describe the textline/chatline. Include information such as: whether it is locally developed or supported by the National Suicide Prevention Lifeline; its hours of operation; and whether it is available to the entire community. |
|
|
5 |
Does the text/chatline involve the use of various technologies (e.g., social media, chat, texting)? |
|
|
6 |
Please indicate the intended audiences/populations of focus for the textline/chatline |
|
|
7 |
Was the textline or chatline implemented as intended based on your work plan? |
Please explain: __________________________ |
|
STRATEGY 7. MEANS RESTRICTION |
|||
Means Restriction Public Awareness Campaign |
|||
Q Num |
Question |
Response Options
|
|
1 |
What is the name of the means restriction public awareness campaign? |
|
|
2 |
Please indicate the date(s) of the public awareness campaign implementation. Select the most specific date as relevant. |
|
|
3 |
Please indicate the location of intended audiences for the public awareness campaign. Select the most specific date(s) as relevant. |
|
|
4 |
Please describe the means restriction public awareness campaign including goals, methods/elements, and intended audiences. |
|
|
5 |
Is the population of focus for this strategy the general population (i.e., the entire community)? |
|
|
6 |
If no, please indicate the populations of focus for the means restriction public awareness campaign. |
|
|
7 |
Does this means restriction awareness campaign place emphasis or focus on any of these current populations at high risk of suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
8 |
Please indicate which of the following elements are used in this means restriction public awareness campaign, and for each selected element, please provide a brief description. Select all that apply. |
|
|
9 |
Was this campaign implemented as intended based on your work plan? |
|
|
Distribution of Gun Locks and Lock Boxes |
||
Q Num |
Question
|
Response Options
|
1 |
What is the name of the distribution activity/event? |
|
2 |
Please indicate the date(s) of the distribution activity or event. Select the most specific date as relevant. |
|
3 |
Please indicate the location(s) of the distribution activity or event. Select the most specific location(s) as relevant. |
|
4 |
Please describe the distribution activity or event. |
|
5 |
Does the distribution activity or event involve the use of technology (e.g., social media, chat, text messaging, social media)? |
|
6 |
Is the population of focus for this distribution activity or event the general population (i.e., the entire community)? |
|
7 |
If no, please indicate the populations of focus for the distribution activity/event. |
|
8 |
Does this gun lock/lock box distribution place emphasis or focus on any of these current priority populations? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
9 |
Was this activity or event implemented as intended based on your work plan? |
|
Means Restriction Activities and Events |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the means restriction activity/event? |
|
|
2 |
Please indicate the date(s) of the activity or event implementation. Select the most specific date as relevant for this approach. |
|
|
3 |
Please indicate the location(s) for activity or event. Select the most specific location(s) as relevant for this approach. |
|
|
4 |
Type of means restriction activity/event: |
|
|
5 |
Please describe the means restriction activity or event. Explain how the activity or event relates to the goals of your suicide prevention program. |
|
|
6 |
Does the means restriction activity/event involve the use of technology (e.g., social media, chat, texting)? |
|
|
7 |
Is the population of focus for this strategy the general population (i.e., the entire community)? |
|
|
8 |
If no, please indicate the populations targeted by the means restriction activity or event. Select all that apply. |
|
|
9 |
Does this means restriction activity or event place emphasis or focus on any of these populations at high risk of suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
10 |
Was the activity implemented as intended based on your work plan? |
|
|
Means Restriction Products |
|||
Q Num |
Question
|
Response Options |
|
1 |
What is the name of the means restriction product? |
|
|
2 |
Please indicate the date(s) of the product implementation. Select the most specific date as relevant to the product development or distribution. |
|
|
3 |
Please indicate the location(s) for the product implementation or distribution. Select the most specific location as relevant. |
|
|
4 |
Type of means restriction product: |
|
|
5 |
Please describe the means restriction product. Explain how this product relates to the goals of your suicide prevention program. |
|
|
6 |
Is the population of focus the general population (i.e., the entire community)? |
|
|
7 |
If no, please indicate the populations of focus for the means restriction product. Select all that apply. |
|
|
8 |
Does this means restriction product place emphasis or focus on any of these populations at high risk of suicide? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
9 |
Was this product implemented as intended based on your work plan? |
|
|
Means Restriction Training |
|
||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the training? |
|
|
2 |
Please indicate the date(s) of the training implementation. Select the most specific date as relevant for this training approach. |
|
|
3 |
Please indicate the delivery method for the training. |
|
|
4 |
[IF TRAINING WAS IN PERSON OR VIRTUAL FACILITATED FROM A CENTRAL LOCATION] Please list the location(s) of the training. |
|
|
5 |
[IF TRAINING WAS VIRTUAL/SELF-DIRECTED] Please indicate the location of intended audiences/trainees. |
|
|
6 |
Please indicate the type of training: |
[IF OTHER] Is this a locally developed training?
|
|
7 |
Please describe the training. If you are using a standard curriculum, you need not describe the content of the curriculum. If you are using a locally developed curriculum, please also describe the content of the curriculum. Provide description such as: why this particular training type has been selected for these particular groups of trainees; how the training has been adapted to meet the needs of this group of trainees; and strategies for recruiting participants. |
|
|
8 |
Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
9 |
Please indicate the types of trainees: |
|
|
10 |
Was this training implemented as intended based on your work plan? |
|
|
Lethal Means Counseling |
|||
Q Num |
Question
|
Response Options
|
|
1 |
Name of service: ______________ |
|
|
2 |
Please indicate the date(s) of implementation of lethal means counseling. Select the most specific date as relevant for this counseling approach. |
|
|
3 |
Please indicate the location(s) where lethal means counseling has been provided. Select the most specific location(s) as relevant for this counseling approach. |
|
|
4 |
Please provide a brief description of the service. |
|
|
5 |
Does lethal means counseling involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
6 |
Was the lethal means counseling implemented as intended based on your work plan? |
Please explain: __________________________ |
|
STRATEGY 8: POLICIES, PROTOCOLS, AND INFRASTRUCTURE |
|||
Policies and Protocols Related to Intervention |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the policy/protocol? |
|
|
2 |
Please indicate the date(s) of the policy or protocol implementation, if relevant. Select the most specific date as relevant for this policy or protocol. |
|
|
3 |
Please indicate the location(s) of the policy or protocol implementation, if relevant. Select the most specific location as relevant to the policy or protocol implementation. |
|
|
4 |
Please describe the purpose of this policy/protocol. Include elements in your description such as procedures for responding to youth at risk, types of agencies/staff involved in the protocol and their respective roles and responsibilities, and description of how the protocol will be communicated, reviewed and evaluated. |
|
|
5 |
Does the policy or protocol involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
6 |
Was this policy or protocol implemented as intended based on your work plan? |
Please explain: __________________________ |
|
Policies and Protocols Related to Postvention |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the policy/protocol? |
|
|
2 |
Please indicate the date(s) of the policy or protocol implementation. Select the most specific date as relevant for this policy or protocol. |
|
|
3 |
Please indicate the location(s) of the policy or protocol implementation, if relevant. |
|
|
4 |
Please describe the purpose of this policy/protocol. Include elements in your description such as postvention procedures for responding to completed suicide, types of agencies/staff involved in the protocol and their respective roles and responsibilities, description of how the protocol will be communicated, reviewed and evaluated, etc. |
|
|
5 |
Does the policy or protocol involve the use of technology (e.g., social media, chat, texting)? |
|
|
6 |
Was this policy or protocol implemented as intended based on your work plan? |
Please explain: __________________________ |
|
Electronic Health Record Implementation and/or Utilization |
||
Q Num |
Question
|
Response Options
|
1 |
Name of service. |
|
2 |
Please indicate the date(s) of the electronic health record implementation and/or utilization. Select the most specific date as relevant for the health record implementation or utilization. |
|
3 |
Please indicate the location(s) for the electronic public health record implementation and/or utilization. Select the most specific location(s) as relevant to the health record implementation or utilization. |
|
4 |
Please describe how electronic health records are used to support suicide prevention efforts. Who is included/involved in implementation? In what setting is the electronic health record utilized? |
|
5 |
In which of the following ways is the electronic health record used to enhance grant activities? |
|
6 |
Was this strategy implemented as intended based on your work plan? |
|
STRATEGY 9: COALITIONS AND PARTNERSHIPS |
|||
Leading or Substantially Supporting a Suicide Prevention Coalition |
|||
Q Num |
Question |
Response Options
|
|
1 |
What is the name of the coalition? |
|
|
2 |
Please indicate the date(s) of implementation of the coalition. Select the most specific date(s) as relevant. |
|
|
3 |
Please indicate the location(s) of suicide prevention strategy implementation and activity promoted by the coalition. Select the most specific location as relevant for this coalition. |
|
|
4 |
Please provide a brief description of the coalition. Include information such as: what types of agencies participate in the coalition; what are the goals of the coalition; what are its major achievements; how frequently do the members meet; strategies for sustaining the coalition, etc. |
|
|
5 |
Does the coalition leverage the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
6 |
Was this coalition implemented as intended based on your work plan? |
Please explain: __________________________ |
|
Leading or Substantially Supporting a Coalition That Is Closely Related to Youth Suicide Prevention |
|||
Q Num |
Question
|
Response Options
|
|
1 |
What is the name of the coalition? |
|
|
2 |
Please indicate the date(s) during which you lead or substantially supported a coalition that is closely related to youth suicide prevention. Select the most specific date as relevant. |
|
|
3 |
Please indicate the location(s) of suicide prevention strategy implementation and activity promoted by the coalition. Select the most specific location as relevant for this coalition. |
|
|
4 |
Please provide a brief description of the coalition. Include information such as: how does your participation in this coalition advance your suicide prevention effort; what types of agencies participate in the coalition; what are the goals of the coalition; what are its major achievements; and how frequently do the members meet. |
|
|
5 |
Does the coalition involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
6 |
Was this coalition implemented as intended based on your work plan? |
Please explain: __________________________ |
|
Participation in Coalitions Related to Youth Prevention |
|||
Q Num |
Question
|
Response Options
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1 |
What is the name of the coalition? |
|
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2 |
Please indicate the date(s) of implementation of the coalition. Select the most specific date(s) as relevant. |
|
|
3 |
Please indicate the location(s) of suicide prevention strategy implementation and activity promoted by the coalition. Select the most specific location as relevant for this coalition. |
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|
4 |
Please provide a brief description of the coalition. Include information such as: how does your participation in this coalition advance your suicide prevention efforts; what types of agencies participate in the coalition; what are the goals of the coalition; what are its major achievements; and how frequently do the members meet, etc. |
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|
5 |
Does the coalition involve the use of technology (e.g., social media, chat, texting)? |
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6 |
Was this coalition implemented as intended based on your work plan? |
Please explain: __________________________ |
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Partnerships With Agencies and Organizations |
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Q Num |
Question
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Response Options
|
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1 |
Name of partnership strategy: ____________________ |
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2 |
Please provide a brief description of your efforts to build partnerships with youth-serving agencies and organizations. |
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3 |
Please indicate the types of agencies and/ or organizations with which you have partnered to implement your program strategies. Please also list the number of agencies or organizations representing each partner type. Select all that apply.
Note: response options will be tailored to grantee type to ensure relevance |
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4 |
[FOR EACH PARTNER TYPE SELECTED UNDER Q3] Which of the following are the primary aspects of your relationship with this partner type? Select all that apply. |
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5 |
[FOR EACH PARTNER TYPE SELECTED UNDER 3] Please indicate the date(s) of partnership implementation. Select the most specific date(s) as relevant. |
|
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6 |
[FOR EACH PARTNER TYPE SELECTED UNDER 3] Please indicate the location of suicide prevention strategy implementation and activity promoted by the partnership. Select the most specific location as relevant for this partnership. |
|
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7 |
[FOR EACH PARTNER TYPE SELECTED UNDER Q3] Was this partnership implemented as intended based on your work plan? |
Please explain: __________________________ |
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STRATEGY 10. DIRECT SERVICES |
||||
Mental Health-Related Services |
||||
Q Num |
Question
|
Response Options
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|
|
1 |
Name of service: ____________________ |
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|
|
2 |
Please indicate the date(s) of mental health service implementation. Select the most specific date(s) as relevant for this service. |
|
|
|
3 |
Please indicate the location(s) of service implementation. Select the most specific location(s) as relevant for this mental health-related service. |
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|
|
4 |
Type of service. Select all that apply. |
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|
|
5 |
Please provide a brief description of the service including any evidence-based practices (including treatments or services) delivered: |
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|
|
6 |
Does the service involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
|
7 |
Have these services been implemented as intended based on your work plan? |
|
|
|
Postvention Services |
||||
Q Num |
Question
|
Response Options
|
|
|
1 |
Name of service: ____________________ |
|
|
|
2 |
Please indicate the date(s) of postvention service implementation. Select the most specific date as relevant. |
|
|
|
3 |
Please indicate the location(s) of postvention service implementation. Select the most specific location(s) as relevant. |
|
|
|
4 |
Please provide a brief description of the service: |
|
|
|
5 |
Does the service involve the use of technology (e.g., social media, chat, texting)? |
|
|
|
6 |
Was this service implemented as intended based on your work plan? |
Please explain: __________________________ |
|
|
Case Management Services |
|||
Q Num |
Question
|
Response Options
|
|
1 |
Name of service: ____________________ |
|
|
2 |
Please indicate the date(s) of case management services. Select the most specific date as relevant. |
|
|
3 |
Please indicate the location(s) of case management services. Select the most specific location(s) as relevant. |
|
|
4 |
Please provide a brief description of the service. |
|
|
5 |
Does the service involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
6 |
Was this service implemented as intended based on your work plan? |
Please explain: __________________________ |
|
Crisis Response Services |
||
Q Num |
Question
|
Response Options
|
1 |
Name of service: ____________________ |
|
2 |
Please indicate the date(s) of crisis response service implementation. Select the most specific date(s) as relevant. |
|
3 |
Please indicate the location(s) where crisis response services were implemented. Select the most specific location (s) as relevant |
|
4 |
Please provide a brief description of the service. |
|
5 |
Does the service involve the use of technology (e.g., social media, chat, text messaging, innovation)? |
|
6 |
Was this service implemented as intended based on your work plan? |
Please explain: __________________________ |
Follow-Up Services |
||
Q Num |
Question
|
Response Options
|
1 |
Name of service: ____________________ |
|
2 |
Please indicate the date(s) of follow-up service implementation. Select the most specific date as relevant. |
|
3 |
Please indicate the location(s) where follow-up services have been provided. Select the most specific location(s) as relevant. |
|
4 |
Please provide a brief description of the service. |
|
5 |
What strategies do you use to follow-up with youth after identification? |
|
6 |
When is this service utilized? |
|
7 |
Please indicate the settings where follow-up services are utilized. Select all that apply. |
|
8 |
Was this service implemented as intended based on your work plan? |
|
STRATEGY 11. TRADITIONAL HEALING PRACTICES |
|||
Traditional Healing Practices |
|||
Q Num |
Question
|
Response Options |
|
1 |
Name of service: ___________ |
|
|
2 |
Please indicate the date(s) of implementation of traditional healing practices. Select the most specific date as relevant for this approach. |
|
|
3 |
Please indicate the location(s) where traditional healing practices have been implemented. Select the most specific location as relevant to your approach. |
|
|
4 |
Please provide a brief description of the service. |
|
|
5 |
Does this practice involve the use of technology (e.g., social media, chat, text messaging, innovations)? |
|
|
6 |
Was this traditional healing practice implemented as intended based on your work plan? |
Please explain: __________________________ |
|
Caring Contacts after Emergency Department Discharge |
||
Q Num |
Question |
Response Options
|
1. |
For youth who have been discharged from the emergency department, does your program provide or coordinate reach out to provide a supportive or caring contact for the purpose of expressing care or concern for the youth? |
|
2. |
Please describe the approach used to provide caring contact(s) for youth after emergency department discharge and how your program is involved. |
|
3. |
Which modes of communication are used to provide caring contacts for youth after emergency department discharge? Select all that apply. |
|
4. |
What is a typical length of time between a youth being discharged from the emergency department and initiation of caring contacts? |
|
5. |
How often are caring contacts provided following a youth's discharge from the emergency department? |
|
6. |
For how long are caring contacts provided following a youth’s discharge from the emergency department? |
|
7. |
Who is responsible for providing caring contacts after youth discharge from an emergency department for the purpose of expressing care or concern for the youth? Select all that apply. |
|
8. |
Is your program implementing an approach to supporting caring contacts for youth after emergency department discharge as intended based on your work plan? |
|
Follow-up after Emergency Department Discharge |
|||
Q Num |
Question |
Response Options
|
|
1. |
For youth who have been discharged from the emergency department, does your program provide or coordinate contacting youth for the purpose of checking in on the status of the youth, for care coordination, or to check in on service receipt? |
|
|
2. |
Please describe the approach used to provide follow up for youth after emergency department discharge and how your program is involved. |
|
|
3. |
Which modes of communication are used to follow up with youth after emergency department discharge? Select all that apply. |
|
|
4. |
What is a typical length of time between youth being discharged from the emergency department and initiation of follow-up? |
|
|
5. |
Who is responsible for monitoring or tracking youth after discharge from an emergency department to ensure that follow-up services (mental health or other support services) are received? Select all that apply. |
|
|
6. |
Is your program supporting follow up with youth after emergency department discharge as intended based on your work plan? |
|
|
Caring Contacts after Inpatient Hospitalization |
||
Q Num |
Question
|
Response Options
|
1. |
For youth who have been discharged from inpatient hospitalization, does your program provide or coordinate reach out to provide a supportive or caring contact for the purpose of expressing care or concern for the youth? |
|
2. |
Please describe the approach used to provide caring contact(s) for youth after inpatient hospitalization discharge and how your program is involved. |
|
3. |
Which modes of communication are used to provide caring contacts for youth after inpatient hospitalization discharge? Select all that apply. |
|
4. |
What is the length of time between a youth being discharged from inpatient hospitalization and initiation of caring contacts? |
|
5. |
How often are caring contacts provided following a youth's discharge from the inpatient hospitalization? |
|
6. |
For how long are caring contacts provided following a youth’s discharge from inpatient hospitalization? |
|
7. |
Who is responsible for providing caring contacts after youth discharge from inpatient hospitalization for the purpose of expressing care or concern for the youth? Select all that apply. |
|
8. |
Is your program supporting caring contacts for youth after inpatient hospitalization discharge as intended based on your work plan? |
|
Follow-up after Inpatient Hospitalization |
||
Q Num |
Question
|
Response Options
|
1. |
For youth who have been discharged from the inpatient hospitalization, does your program provide or coordinate contacting youth for the purpose of checking in on the status of the youth, for care coordination, or to check in on service receipt? |
|
2. |
Please describe the approach used to provide follow up for youth after inpatient hospitalization discharge and how your program is involved. |
|
3. |
Which modes of communication are used to follow up with youth after inpatient hospitalization discharge? Select all that apply. |
|
4. |
What is a typical length of time between youth being discharged from the inpatient hospitalization and initiation of follow-up? |
|
5. |
Who is responsible for monitoring or tracking youth after discharge from an inpatient hospitalization to ensure that follow-up services (mental health or other support services) are received? Select all that apply. |
|
6. |
Is your program supporting follow up with youth after inpatient hospitalization discharge as intended based on your work plan? |
|
STRATEGY 13: OTHER SUICIDE PREVENTION STRATEGIES |
|||
Q Num |
Question
|
Response Options
|
|
1 |
Name of suicide prevention strategy: |
|
|
2 |
Please indicate the date(s) of implementation of this suicide prevention strategy. Select the most specific date as relevant. |
|
|
3 |
Please indicate the location(s) where this strategy was implemented. Select the most specific location(s) as relevant. |
|
|
4 |
Type of suicide prevention strategy. |
|
|
5 |
Please provide a brief description of this suicide prevention strategy. Include information such as type of strategy and target populations. |
|
|
6 |
Does the suicide prevention strategy involve the use of technology (e.g., social media, chat, texting)? |
|
|
7 |
Does this strategy place emphasis or focus on any of these current priority populations? Select all that apply. |
[If selected] Are youth connected to school or related systems?
|
|
11 |
Was this suicide prevention activity implemented as intended based on your work plan? |
|
|
How much of your GLS budget, including any matching funds, have you spent to date?
Specify dollar amount: ______
Please estimate the percentage of your total budget expended to date on the following prevention strategies. [ONLY MAJOR STRATEGY (BOLD CAPS) ARE REQUIRED]
OUTREACH AND AWARENESS |
____% |
Public awareness campaigns |
____% |
Outreach and awareness activities and events |
____% |
Outreach and awareness products |
____% |
GATEKEEPER TRAINING |
____% |
School-based adult gatekeeper training |
____% |
School-based peer gatekeeper training |
____% |
Community-based adult gatekeeper training |
____% |
Community-based peer gatekeeper training |
____% |
ASSESSMENT, CLINICAL, AND REFERRAL TRAINING |
____% |
For mental health professionals |
____% |
For hotline staff |
____% |
LIFE SKILLS AND WELLNESS DEVELOPMENT |
____% |
Life skills development for youth curricula |
____% |
Cultural activities |
____% |
Wellness activities |
____% |
SCREENING PROGRAMS |
____% |
HOTLINES, HELPLINES, TEXTLINES, AND CHATLINES |
____% |
Hotlines and helplines |
____% |
Textlines and chatlines |
____% |
MEANS RESTRICTION |
____% |
Means restriction public awareness campaigns |
____% |
Distribution of gun locks and lock boxes |
____% |
Means restriction activities and events |
____% |
Means restriction products |
____% |
Means restriction training |
____% |
Lethal means counseling |
____% |
POLICIES, PROTOCOLS, AND INFRASTRUCTURE |
____% |
Related to intervention |
____% |
Related to postvention |
____% |
Electronic health record implementation/utilization |
____% |
COALITIONS AND PARTNERSHIPS |
____% |
Leading or substantially supporting a suicide prevention coalition |
____% |
Leading or substantially supporting a coalition that is closely related to youth suicide prevention |
____% |
Participating in coalitions related to youth prevention |
____% |
Partnerships with agencies and organizations |
____% |
DIRECT SERVICES AND TRADITIONAL HEALING PRACTICES |
____% |
Mental health-related services |
____% |
Postvention services |
____% |
Case management services |
____% |
Crisis response services |
____% |
Traditional healing practices |
____% |
Follow-up services |
____% |
CARE TRANSITIONS |
____% |
Follow-up after emergency department discharge |
____% |
Follow-up after inpatient hospitalization |
____% |
OTHER SUICIDE PREVENTION STRATEGY |
____% |
1 Healthy People 2030, https://health.gov/healthypeople/priority-areas/social-determinants-health; Centers of Disease Control and Prevention, Social Determinants of Health, December 2022: https://www.cdc.gov/about/sdoh/index.html.
2 Response options are adapted based on the following references: Academy of Family Physicians (2018). Social Determinants of Health Guide to Social Needs Screening. https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/sdoh-guide.pdf; Healthy People 2030, https://health.gov/healthypeople/priority-areas/social-determinants-health American Academy of Pediatrics, 2020: https://downloads.aap.org/AAP/PDF/SDOH.pdf.
3 Schell, S.F., Luke, D.A., Schooley, M.W. et al. Public health program capacity for sustainability: a new framework. Implementation Sci 8, 15 (2013). https://doi.org/10.1186/1748-5908-8-15;
Shelton RC, Cooper BR, Stirman SW. The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care. Annu Rev Public Health. 2018 Apr 1;39:55-76. doi: 10.1146/annurev-publhealth-040617-014731. Epub 2018 Jan 12. PMID: 29328872;
Luke DA, Calhoun A, Robichaux CB, Elliott MB, Moreland-Russell S. The Program Sustainability Assessment Tool: a new instrument for public health programs. Prev Chronic Dis. 2014 Jan 23;11:130184. doi: 10.5888/pcd11.130184. PMID: 24456645; PMCID: PMC3900326.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Douglas, Elizabeth |
| File Modified | 0000-00-00 |
| File Created | 2023-12-12 |