Prevention Strateg Prevention Strategies Inventory (PSI)

Garrett Lee Smith (GLS) State/Tribal Youth Suicide Prevention and Early Intervention Evaluation

Att B.1 PSI for OMB_clean 7_24_23 final

OMB: 0930-0286

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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

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
These are policies and protocols utilized by a special team formed to respond to youth at risk or to crisis situations, and to involve various individuals, agencies and services, including mental health centers, hospitals, mobile crisis teams, police, parents/guardians, etc. Policies and protocols are formally written statements documenting the procedures to be followed. This strategy also includes infrastructure development related to the utilization of electronic health records to enhance suicide prevention efforts.

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.
COALITIONS AND PARTNERSHIPS

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.

PSI Organization and Modules

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.

Behavioral Health Equity Module

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

  • Obtained input from the communities served by our program to understand cultural health beliefs and practices, values, needs, and expectations and to guide program design and implementation

  • Obtained input from the community representing a diversity of perspectives with consideration of age, gender identity, race, or ethnicity to guide program design and implementation

  • Obtained input from individuals with lived experience (i.e., survivors of loss and survivors of suicide attempts including youth and their families) to guide program design and implementation

  • Partnered with community-based organizations and community leaders to engage communities in efforts to examine and address health disparities


Staffing and advisory board

  • Trained staff on culturally responsive and equitable practices

  • Hired staff representing the communities served by our program and/or with lived experience to support outreach and engagement

  • Included individuals representing communities served and/or those with lived experience on our advisory board


Language and literacy

  • Improved language accessibility by providing interpreters and translated materials

  • Strengthened the health literacy and other communication needs of subgroups in the proposed geographic region


Implementation focus

  • Implemented strategies designed to address the suicide-related risk and protective factors specific to the populations served by our program

  • Implemented strategies designed to address the social determinants of health relevant to the populations served by our program

  • Implemented our program in high-need communities to address disproportionate youth suicide risk and promote health equity


Other

  • Other, please describe


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.


  • Adaptation to address cultural traditions or beliefs related to health and health-related practices to ensure culturally responsive services

  • Please describe examples of such cultural adaptations

  • Adaptation to address preferred languages

  • Adaptation to improve health literacy

  • Adaptation to address the input and perspectives of individuals with lived experience (i.e., survivors of loss and survivors of suicide attempts including youth and their families)

  • Adaptation to address the input of community members served by the program

  • Adaptation to address the specific suicide-related risk and protective factors of the communities served by the program

  • Please describe examples of such population-specific risk and protective factors addressed

  • Other, please describe



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.


  • Access to quality medical/health care

  • Access to nutritious foods and/or physical activity opportunities

  • Access to clean water and functioning utilities (e.g., electricity, sanitation, heating, and cooling)

  • Early childhood social and physical environment, including childcare

  • Education opportunities

  • Ethnicity and cultural orientation

  • Familial and other social support

  • Safe housing and/or transportation resources

  • Language and literacy skills

  • Neighborhood safety and recreational facilities

  • Occupation opportunities and job security

  • Exposure to violence and other adverse experiences

  • Racism and discrimination

  • Sexual identification

  • Social status (degree of integration vs. isolation)

  • Socioeconomic status

  • Spiritual/religious values

  • Other, please explain2


5b.

Please provide a description of how the SDoH have been addressed through implementation of (display strategy title).


(Open-ended)



Sustainability Module

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.



  • We do not intend to sustain this strategy after the end of the GLS State/Tribal grant funding period.

  • We intend to sustain all or some of the activities implemented as part of this strategy but have not yet considered specific sustainability plans or formal mechanisms.

  • We are developing or have developed plans to sustain all or some of the activities included as part of this strategy after the end of the grant funding period. (Note: Select this option if you have begun to identify options for sustaining the strategy, or have a sustainability plan, but formal sustainability mechanisms are not yet in place).

  • We already have formal mechanisms in place to sustain all or some of the activities included as part of this strategy after the end of the grant funding period (Note: Select this option if you are ready to sustain the strategy after your funding period. This would be relevant if you have already identified a funding source to continue grant-related strategies and activities; modified policies or practices to sustain the strategy; or if you have identified ways to integrate the strategy into existing program processes).

  • Other, please explain

  • Don’t know


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.



  • We do not intend to sustain this strategy after the end of the GLS State/Tribal grant funding period.

  • We intend to sustain all or some of the activities implemented as part of this strategy but have not yet considered specific sustainability plans or formal mechanisms.

  • We are developing or have developed plans to sustain all or some of the activities included as part of this strategy after the end of the grant funding period. (Note: Select this option if you have begun to identify options for sustaining the strategy, or have a sustainability plan, but formal sustainability mechanisms are not yet in place).

  • We already have formal mechanisms in place to sustain all or some of the activities included as part of this strategy after the end of the grant funding period (Note: Select this option if you are ready to sustain the strategy after your funding period. This would be relevant if you have already identified a funding source to continue grant-related strategies and activities; modified policies or practices to sustain the strategy; or if you have identified ways to integrate the strategy into existing program processes).

  • Other, please explain

  • Don’t know


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.



  • Local organizations adopting service priorities to support progress made under this award

  • Continued existing partnerships with organizations and agencies

  • Continued participation in existing coalitions

  • Newly developed partnerships with organizations and agencies

  • Other suicide prevention grants or funding streams

    • (If selected, please select all that apply and list program/initiative names):

SAMHSA grants__

Other Federal grants__

State__

Local__

Organization/nonprofit__

Other__

  • Other grants or funding streams not specific to suicide prevention (e.g., substance abuse treatment)

    • (If selected, please specify)

  • Other, please describe

  • N/A

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.

  • Allows for streamlined staffing and expertise across suicide prevention initiatives

  • Facilitates implementation of evidence-based practices more efficiently or extensively

  • Contributes to expanded gatekeeper training for additional audiences

  • Supports our program in reaching additional populations such as underserved populations

  • Supports leveraging partnerships with organizations and agencies to meet aligned suicide prevention goals across initiatives

  • Other, please describe

(Include multiple “Other” fields as needed)



Quarterly PSI

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).


  • Goal 1: Integrate and coordinate suicide prevention activities across multiple sectors and settings.

  • Goal 2: Implement research-informed communication efforts designed to prevent suicide by changing knowledge, attitudes, and behaviors.

  • Goal 3: Increase knowledge of the factors that offer protection from suicidal behaviors and that promote wellness and recovery.

  • Goal 4: Promote responsible media reporting of suicide, accurate portrayals of suicide and mental illnesses in the entertainment industry, and the safety of online content related to suicide.

  • Goal 5: Develop, implement, and monitor effective programs that promote wellness and prevent suicide and related behaviors.

  • Goal 6: Promote efforts to reduce access to lethal means of suicide among individuals with identified suicide risk.

  • Goal 7: Provide training to community and clinical service providers on the prevention of suicide and related behaviors.

  • Goal 8: Promote suicide prevention as a core component of health care services.

  • Goal 9: Promote and implement effective clinical and professional practices for assessing and treating those identified as being at risk for suicidal behaviors.

  • Goal 10: Provide care and support to individuals affected by suicide deaths and attempts to promote healing and implement community strategies to help prevent further suicides.

  • Goal 11: Increase the timeliness and usefulness of national surveillance systems relevant to the suicide prevention and improve the ability to collect, analyze, and use this information for action.

  • Goal 12: Promote and support research on suicide prevention.

  • Goal 13: Evaluate the impact and effectiveness of suicide prevention interventions and systems and synthesize and disseminate findings.



Quarterly PSI: Sub-Strategy Questions

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A

3

Please indicate the location of intended audiences for the public awareness campaign. Select the most specific location as relevant to the campaign.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

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)?

  • Yes [Go to Q. 8]

  • No [Continue with Q.6]

6

If no, please indicate the primary intended audience for the public awareness campaign. Choose only one response.

  • Youths/students

  • Parents/guardians

  • Mental health professionals

  • Child welfare staff

  • University college/faculty staff

  • Juvenile justice staff

  • Primary care staff

  • Education staff

  • Other, please specify

7

Please indicate any additional intended audiences for the public awareness campaign. Select all that apply.

  • Youths/students

  • Parents/guardians

  • Mental health professionals

  • Child welfare staff

  • University college/faculty staff

  • Juvenile justice staff

  • Primary care staff

  • Education staff

  • Other, please specify

8

Does your campaign place emphasis or focus on any of these populations at high risk for suicide? Select all that apply.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual transgender, and queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify

9

Please indicate which of the following elements are used in this public awareness campaign.

  • Print materials such as brochures, posters, and flyers. Please describe: _______________

  • Print media such as magazines or newsletters. Please describe: ____________

  • Billboards. Please describe: ____________________

  • Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.) Please describe: ____________________

  • Web site development/enhancement. Please describe: ____________________

  • Social media (Facebook, Twitter, Instagram, etc.) Please describe: ______________

  • Other uses of technology (e.g., chat, text messaging, innovations). Please describe: _______________

  • Radio. Please describe: ____________________

  • TV. Please describe: ____________________

  • Events/activities. Please describe: ____________________

  • Booth at health fair. Please describe: ____________________

  • Other, please describe: ____________________

10

Was this campaign implemented as intended based on your work plan?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing



3

Please indicate the location(s) of the activity/event. Select the most specific location relevant for this activity/event.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


4

Type of activity/event

  • Participation in a health fair (e.g., booth or table)

  • Awareness walk (e.g., Out of Darkness)

  • Poster contest

  • Awareness/informational presentation

  • Other, please specify


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)?

  • Yes

    • Please describe technology used_____________

  • No


8

Is the activity or event intended for the general population (i.e., the entire community)?

  • Yes [Go to Q. 10]

  • No [Continue with Q.9]


9

If no, please indicate the primary population of focus for this activity or event. Choose only one response.

  • Youths/students

  • Parents/guardians

  • Mental health professionals

  • Child welfare staff

  • Faculty/staff at university/college

  • Juvenile justice staff

  • Primary care staff

  • Education staff

  • Other, please specify


10

Please indicate any additional populations of focus for the activity or event. Select all that apply.

  • Youths/students

  • Parents/guardians

  • Mental health professionals

  • Child welfare staff

  • University college/faculty staff

  • Juvenile justice staff

  • Primary care staff

  • Education staff

  • Other, please specify


11

Does this activity/event place emphasis or focus on any of these populations at high risk for suicide? Select all that apply.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


12

Was this activity or event implemented as intended based on your work plan?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the location(s) of the intended audience for this product. Select the most specific location as relevant.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


4

Type of product

  • Print materials such as brochures, posters, and flyers

  • Print media such as newspapers/magazines/newsletters

  • Billboards

  • Awareness products (such as stress balls, key chains, mood pens, T-shirts etc.)

  • Mobile applications

  • Web site development/enhancement

  • Social media (Facebook, Twitter, Instagram, etc.)

  • Other uses of technology (e.g., chat, text messaging, other innovations). Please describe: _______________

  • Radio

  • TV

  • Other, please specify


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)?

  • Yes [Go to Q. 10]

  • No [Continue with Q.8]


8

If no, please indicate the primary population of focus for the product. Choose only one response.

  • Youths/students

  • Parents/guardians

  • Mental health professionals

  • Child welfare staff

  • Faculty/staff at university/college

  • Juvenile justice staff

  • Primary care staff

  • Education staff

  • Other, please specify


9

Please indicate any additional populations of focus for the product. Select all that apply.

  • Youths/students

  • Parents/guardians

  • Mental health professionals

  • Child welfare staff

  • University college/faculty staff

  • Juvenile justice staff

  • Primary care staff

  • Education staff

  • Other, please specify


10

Does this product place emphasis or focus on any of these populations at high risk for suicide? Select all that apply.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, and transgender and queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


11

Does the product or its dissemination involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

    • Please describe technology used_____________

  • No


12

Was this product produced and/or disseminated as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________




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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing




3

Please indicate the delivery method for the training.

  • In person

  • Virtual (facilitated on a specific date)

  • Virtual (self-directed; trainee completes training at own time)

  • Multiple methods, please explain: _____

  • Other, please explain: ____________


4

Please indicate the type of training:

  • QPR (Question, Persuade, Refer)

  • ASIST (Applied Suicide Intervention Skills Training)

  • safeTALK

  • Lifelines

  • Signs of Suicide (SOS)

  • Other, please specify

[IF OTHER] Is this a locally developed training?

    • Yes

    • No


5

Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

    • Please describe technology used_____________

  • No


6

Were the trainees members of the general population (i.e., the entire community)?

  • Yes [Go to Q.8]

  • No [Continue with Q.7]


7

If no, please indicate the types of trainees. Select all that apply.

  • Teacher

  • School administrator

  • Mental health clinician/counselor/psychologist

  • Social worker/caseworker/care coordinator

  • Emergency/crisis care worker

  • Administrative assistant/clerical support personnel

  • Academic advisor

  • Coach

  • Cafeteria staff

  • Other, please specify


8

Does this training place emphasis or focus on any of these populations at high risk for suicide? Select all that apply.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


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?

  • Yes

  • No

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.

  • Youth information is entered into an electronic database; electronic alerts at specified follow-up intervals.

  • Trainee responsible for tracking and monitoring follow-up

  • Grant staff responsible for tracking and monitoring follow-up

  • Care coordinator responsible for tracking and monitoring follow-up

  • None

  • Other process, please describe: __________________


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.

  • Trainee follows up with youth to determine why services have not been received

  • Trainee follows up with parent/guardian to determine why services have not been received

  • Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow-up

  • Other process, please describe: ________________________________



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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing



3

Please indicate the delivery method for the training.

  • In person

  • Virtual (facilitated on a specific date)

  • Virtual (self-directed; trainee completes training at own time)

  • Multiple methods, please explain: _____

  • Other, please explain: ____________


4

Please indicate the type of training.

  • Yellow Ribbon

  • Signs of Suicide (SOS)

  • Youth Depression & Suicide: Let’s Talk

  • Lifelines

  • Sources of Strength

  • QPR (Question, Persuade, Refer)

  • Other, please specify

[IF OTHER] Is this a locally developed training?

    • Yes

    • No


5

Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

Please describe technology used_____________

  • No


6

Were the trainees members of the general population (i.e., the entire community)?

  • Yes [Go to Q. 8]

  • No [Continue with Q.7]


7

If no, please indicate the types of trainees. Select all that apply.

  • All students

  • Selected peer “natural helpers”

  • Other, please specify: ____________________


8

Does this training place emphasis or focus on any of these current priority populations at high risk for suicide? Select all that apply.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


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?

  • Yes

  • No

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.

  • Youth information is entered into an electronic database; electronic alerts at specified follow-up intervals.

  • Trainee responsible for tracking and monitoring follow-up

  • Grant staff responsible for tracking and monitoring follow-up

  • Care coordinator responsible for tracking and monitoring follow-up

  • None

  • Other process, please describe: _________________


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.

  • Trainee follows up with youth to determine why services have not been received

  • Trainee follows up with parent/guardian to determine why services have not been received

  • Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow-up

  • Other process, please describe: _________________



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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the delivery method for the training.

  • In person

  • Virtual (facilitated on a specific date)

  • Virtual (self-directed; trainee completes training at own time)

  • Multiple methods, please explain: _____

  • Other, please explain: ____________


4

Please indicate the type of training:

  • QPR (Question, Persuade, Refer)

  • ASIST (Applied Suicide Intervention Skills Training)

  • safeTALK

  • Lifelines

  • Signs of Suicide (SOS)

  • Other, please specify

[IF OTHER] Is this a locally developed training?

    • Yes

    • No


5

Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

    • Please describe technology used_____________

  • No


6

Were the trainees members of the general population (i.e., the entire community)?

  • Yes [Go to Q. 8]

  • No [Continue with Q.7]


7

If no, please indicate the types of trainees. Select all that apply.

  • Parents/guardians

  • Mental health professionals

  • Child welfare staff

  • University college/faculty staff

  • Juvenile justice staff

  • Primary care staff

  • Education staff

  • Other, please specify


8

Does this training place emphasis or focus on any of these current priority populations? Select all that apply.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


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?

  • Yes

  • No

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.

  • Youth information is entered into an electronic database; electronic alerts at specified follow-up intervals.

  • Trainee responsible for tracking and monitoring follow-up

  • Grant staff responsible for tracking and monitoring follow-up

  • Care coordinator responsible for tracking and monitoring follow-up

  • None

  • Other process, please describe: __________________


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.

  • Trainee follows up with youth to determine why services have not been received

  • Trainee follows up with parent/guardian to determine why services have not been received

  • Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow-up

  • Other process, please describe: ________________________________



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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the delivery method for the training.

  • In person

  • Virtual (facilitated on a specific date)

  • Virtual (self-directed; trainee completes training at own time)

  • Multiple methods, please explain: _____

  • Other, please explain: ____________


4

Please indicate the type of training.

  • Yellow Ribbon

  • Signs of Suicide (SOS)

  • Youth Depression & Suicide: Let’s Talk

  • Lifelines

  • Sources of Strength

  • QPR (Question, Persuade, Refer)

  • Other, please specify

[IF OTHER] Is this a locally developed training?

    • Yes

    • No


5

Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

Please describe technology used_____________

  • No


6

Were the trainees members of the general population (i.e., the entire community)?

  • Yes [Go to Q. 108]

  • No [Continue with Q.97]


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.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, and transgender, queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


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?

  • Yes

  • No

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.

  • Youth information is entered into an electronic database; electronic alerts at specified follow-up intervals.

  • Trainee responsible for tracking and monitoring follow-up

  • Grant staff responsible for tracking and monitoring follow-up

  • Care coordinator responsible for tracking and monitoring follow-up

  • None

  • Other process, please describe: __________________


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.

  • Trainee follows up with youth to determine why services have not been received

  • Trainee follows up with parent/guardian to determine why services have not been received

  • Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow-up

  • Other process (please describe): ________________________________



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

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the delivery method for the training.

  • In person

  • Virtual (facilitated on a specific date)

  • Virtual (self-directed; trainee completes training at own time)

  • Multiple methods, please explain: _____

  • Other, please explain: ____________


4

Please indicate the type of training:

  • AMSR (Assessing and Managing Suicide Risk)

  • RRSR (Recognizing and Responding to Suicide Risk)

  • Cognitive Behavioral Therapy (CBT)

  • Chronological Assessment of Suicide Events (CASE)

  • Dialectical Behavior Therapy (DBT)

  • Mental Health First Aid

  • QPR for Nurses

  • QPR for Physicians, Physician Assistants, Nurse Practitioners, and Others

  • Other, please specify: ____________________

[IF OTHER] Is this a locally developed training?

    • Yes

    • No


5

Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

    • Please describe technology used_____________

  • No


6

Please indicate the types of trainees.

  • Mental health clinician/counselor/ psychologist

  • Social Worker/caseworker/care coordinator

  • Other, please specify


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?

  • Yes

  • No

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.

  • Youth information are entered into an electronic database; electronic alerts at specified follow-up intervals

  • Trainee responsible for tracking and monitoring follow-up

  • Grant staff responsible for tracking and monitoring follow-up

  • Care coordinator responsible for tracking and monitoring follow-up

  • None

  • Other process, please describe: __________________


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.

  • Trainee follows up with youth to determine why services have not been received

  • Trainee follows up with parent/guardian to determine why services have not been received

  • Grant staff responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Care coordinator responsible for following up with youth and/or parent/guardian to determine why services have not been received

  • Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow-up

  • Other process, please describe: ________________________________


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

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the delivery method for the training.

  • In person

  • Virtual (facilitated on a specific date)

  • Virtual (self-directed; trainee completes training at own time)

  • Multiple methods, please explain: _____

  • Other, please explain: ____________


4

Please indicate the type of training:

  • QPR (Question, Persuade, Refer)

  • ASIST (Applied Suicide Intervention Skills Training)

  • safeTALK

  • Lifelines

  • Signs of Suicide (SOS)

  • Other, please specify: ____________________

[IF OTHER] Is this a locally developed training?

    • Yes

    • No


5

Does the training involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

    • Please describe technology used_____________

  • No


6

Please indicate the types of trainees.

  • Mental health clinician/counselor/psychologist

  • Social Worker/caseworker/care coordinator

  • Volunteers

  • Other, please specify


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?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the delivery method for the curriculum.

  • In person

  • Virtual (facilitated on a specific date)

  • Multiple methods, please explain: _____

  • Other, please explain: ____________


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.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


5

Type of curriculum.


  • American Indian Life Skills Development Curriculum

  • Gathering Of Native Americans

  • Other, please specify: ____________________

[IF OTHER] Is this a locally developed training?

    • Yes

    • No


6

Does the curriculum involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

    • Please describe technology used_____________

  • No


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.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


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?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the location(s) where the cultural activities were implemented. Select the most specific location as relevant for this cultural activity.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


4

Type of activity.


  • Culture camp

  • Canoe trips

  • Maze

  • High Rope

  • Traditional arts and crafts

  • Drumming event

  • Dancing event

  • Ceremonies

  • Other, please specify


5

Please describe the activity.



6

Does the activity involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

    • Please describe technology used_____________

  • No


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.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or
related systems?

    • Yes

    • No

  • No

  • Other, please specify


9

Were the cultural activities implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________



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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the location(s) where the activities were implemented. Select the most specific location as relevant to these activities.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


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)?

  • Yes

    • Please describe technology used_____________

No


6

Does this wellness activity place emphasis or focus on any of these populations at high risk for suicide? Select all that apply.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or
related systems?

    • Yes

    • No

  • No

  • Other, please specify


7

Was this wellness activity implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________




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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the location(s) of the screening program implementation. Select the most specific location(s) as relevant for this screening program.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


4

Please indicate the type of screening tool:

  • Patient Health Questionnaire (PHQ-9)

  • Columbia Suicide Severity Rating Scale (CSSR-S)

  • Behavioral Health Screen (BHS)

  • Ask Suicide Screening Questions (asQ)

  • Beck Depression Inventory (BDI)

  • Suicide Behaviors Questionnaire (SBQ-R)

  • Other, please specify

[IF OTHER] Is this a locally developed screening
program?

    • Yes

    • No


5

Please describe the screening program.



6

Does the screening program involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

    • Please describe technology used_____________

  • No


7

Please indicate the settings that are the focus of the screening program. Select all that apply.

  • Child welfare

  • Education (K-12)

  • Emergency response

  • Higher education (college/university)

  • Juvenile justice/Probation

  • Law enforcement

  • Mental Health

  • Primary health care (other than mental health)

  • Substance abuse treatment

  • Tribal services/Tribal government

  • Other community settings

  • Don’t know


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.

  • Screener follows up with youth to determine if services have been received

  • Screener follows up with parent/guardian of youth to determine if services have been received

  • Screener follows up with referral to determine if services have been received

  • Youth are flagged in an electronic database and an alert is provided at weekly intervals for follow-up

  • No systems in place

  • Other process, please describe: ____________________


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.

  • Youth information are entered into an electronic database; electronic records database alert at specified intervals

  • Screener responsible for tracking and monitoring follow-up

  • Care coordinator responsible for tracking/monitoring follow-up

  • No systems in place

  • Other process, please describe: ____________________


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.

  • Screener follows up with youth to determine why services have not been received

  • Screener follows up with parent/guardian to determine why services have not been received

  • Youth are flagged in an electronic database and an alert is provided at weekly (or some other interval) intervals for follow-up

  • No systems in place

  • Other process, please describe: ____________________



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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the intended location for the hotline/helpline. Select the most specific location(s) as relevant for this hotline/helpline service.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


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)?

  • Yes

    • Please describe technology used_____________

  • No


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?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



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.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


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)?

  • Yes

    • Please describe technology used_____________

  • No


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?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the location of intended audiences for the public awareness campaign. Select the most specific date(s) as relevant.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

    • State (allow for state selection).


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)?

  • Yes [Go to Q. 8]

  • No [Continue with Q.7]


6

If no, please indicate the populations of focus for the means restriction public awareness campaign.

  • Youth/Students

  • Parents/Guardians

  • Mental Health Professionals

  • Child Welfare Staff

  • University College/Faculty Staff

  • Juvenile Justice Staff

  • Primary Care Staff

  • Education Staff

  • Other, please specify


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.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


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.

  • Print materials such as brochures, posters, and flyers. Please describe: _______________

  • Print media such as newspapers/magazines/newsletters. Please describe: ____________

  • Billboards. Please describe: ____________________

  • Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.) Please describe: ____________________

  • Website development/enhancement. Please describe: ____________________

  • Social media (Facebook, Twitter, Instagram, etc.) Please describe: ____________________

  • Other uses of technology (e.g., social media, chat, text messaging, innovations)

  • Radio. Please describe: ____________________

  • TV. Please describe: ____________________

  • Events/activities. Please describe: ____________________

  • Booth at health fair. Please describe: ____________________

  • Other, please describe


9

Was this campaign implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________



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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the location(s) of the distribution activity or event. Select the most specific location(s) as relevant.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

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)?

  • Yes

    • Please describe technology used_____________

  • No

6

Is the population of focus for this distribution activity or event the general population (i.e., the entire community)?

  • Yes [Go to Q. 8]

  • No [Continue with Q.7]

7

If no, please indicate the populations of focus for the distribution activity/event.

  • Youth/Students

  • Parents/Guardians

  • Mental Health Professionals

  • Child Welfare Staff

  • University College/Faculty Staff

  • Juvenile Justice Staff

  • Primary Care Staff

  • Education Staff

  • Other, please specify

8

Does this gun lock/lock box distribution place emphasis or focus on any of these current priority populations? Select all that apply.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify

9

Was this activity or event implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________


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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the location(s) for activity or event. Select the most specific location(s) as relevant for this approach.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


4

Type of means restriction activity/event:

  • Participation in a health fair (e.g., booth or table)

  • Awareness walk (e.g., Out of Darkness)

  • Poster contest

  • Awareness/informational presentation

  • Other, please specify


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)?

  • Yes

    • Please describe technology used_____________

  • No


7

Is the population of focus for this strategy the general population (i.e., the entire community)?

  • Yes [Go to Q. 9]

  • No [Continue with Q.8]


8

If no, please indicate the populations targeted by the means restriction activity or event. Select all that apply.

  • Youth/Students

  • Parents/Guardians

  • Mental Health Professionals

  • Child Welfare Staff

  • University College/Faculty Staff

  • Juvenile Justice Staff

  • Primary Care Staff

  • Education Staff

  • Other, please specify


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.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) populations

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


10

Was the activity implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________



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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the location(s) for the product implementation or distribution. Select the most specific location as relevant.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


4

Type of means restriction product:

  • Print materials such as brochures, posters, and flyers

  • Print media such as newspapers/magazines/newsletters

  • Billboards

  • Awareness products (such as stress balls, key chains, mood pens, T-shirts, etc.)

  • Mobile applications

  • Web site development/enhancement

  • Social media (Facebook, Twitter, Instagram, etc.)

  • Other uses of technology (e.g., social media, chat, text messaging, innovations)

  • Radio

  • TV

  • Other, please specify


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)?

  • Yes [Go to Q. 9]

  • No [Continue with Q.8]


7

If no, please indicate the populations of focus for the means restriction product. Select all that apply.

  • Youth/Students

  • Parents/Guardians

  • Mental Health Professionals

  • Child Welfare Staff

  • University College/Faculty Staff

  • Juvenile Justice Staff

  • Primary Care Staff

  • Education Staff

  • Other, please specify


8

Does this means restriction product place emphasis or focus on any of these populations at high risk of suicide? Select all that apply.

  • American Indian/Alaska Native persons

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance use disorders

  • Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ+) persons

  • Veterans, active military, or military families

  • Hispanic or Latino persons

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


9

Was this product implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________



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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the delivery method for the training.

  • In person

  • Virtual (facilitated on a specific date)

  • Virtual (self-directed; trainee completes training at own time)

  • Multiple methods, please explain: _____

  • Other, please explain: ____________

4

[IF TRAINING WAS IN PERSON OR VIRTUAL FACILITATED FROM A CENTRAL LOCATION] Please list the location(s) of the training.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

5

[IF TRAINING WAS VIRTUAL/SELF-DIRECTED] Please indicate the location of intended audiences/trainees.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

6

Please indicate the type of training:

  • CALM (Counseling on Access to Lethal Means)

  • Other, please specify

[IF OTHER] Is this a locally developed training?

  • Yes

  • No

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)?

  • Yes

    • Please describe technology used_____________

  • No

9

Please indicate the types of trainees:

  • Mental Health clinician/counselor/psychologist

  • Social Worker/Caseworker/Care coordinator

  • Other, please specify

10

Was this training implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________


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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



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.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


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)?

  • Yes

    • Please describe technology used_____________

  • No


6

Was the lethal means counseling implemented as intended based on your work plan?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



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.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

  • N/A


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)?

  • Yes

    • Please describe technology used_____________

  • No


6

Was this policy or protocol implemented as intended based on your work plan?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the location(s) of the policy or protocol implementation, if relevant.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

  • N/A


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)?

  • Yes

    • Please describe technology used_____________

  • No


6

Was this policy or protocol implemented as intended based on your work plan?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


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.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

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?

  • Suicide screening and risk assessment

  • Monitoring progress and follow-up of youth after identification

  • Communication between multiple providers

  • Creating and sharing safety plans with youth and/or families

  • Tracking scheduled appointments

  • Tracking suicide attempts or deaths

  • Other, please specify

6

Was this strategy implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________


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.

  • MM_DD_YY to MM_DD_YY

  • Ongoing since the beginning of the grant

  • Ongoing based on a long history collaborating with this coalition

  • Other, please specify


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.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

  • N/A


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)?

  • Yes

    • Please describe technology used_____________

  • No


6

Was this coalition implemented as intended based on your work plan?

  • Yes

  • No

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.

  • MM_DD_YY to MM_DD_YY

  • Ongoing since the beginning of the grant

  • Ongoing based on a long history collaborating with this coalition

  • Other, please specify


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.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

  • N/A


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)?

  • Yes

    • Please describe technology used_____________

  • No


6

Was this coalition implemented as intended based on your work plan?

  • Yes

  • No

Please explain: __________________________



Participation in Coalitions Related to Youth Prevention

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.

  • MM_DD_YY to MM_DD_YY

  • Ongoing since the beginning of the grant

  • Ongoing based on a long history collaborating with this coalition

  • Other, please specify


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.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


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.



5

Does the coalition involve the use of technology (e.g., social media, chat, texting)?

  • Yes

    • Please describe technology used_____________

  • No


6

Was this coalition implemented as intended based on your work plan?

  • Yes

  • No

Please explain: __________________________



Partnerships With Agencies and Organizations


Q Num

Question


Response Options


1

Name of partnership strategy: ____________________


2

Please provide a brief description of your efforts to build partnerships with youth-serving agencies and organizations.


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

Agency/organization types

Number of each type

Mental health/behavioral health agency


Child welfare services (i.e., social services) agency


K-12 school


College or university


Juvenile justice/probation agency


Law enforcement agency


Emergency response


State health department agency


Local health department agency


Primary care provider


Crisis center


Substance abuse treatment center


Tribal health agency


Tribal social services agency


Tribal government


Nonprofit community service
organization


Individual therapist


Religious or spiritual organization


Other, please specify:


Other, please specify:


Other, please specify:


Not applicable



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.

  • Coordination of gatekeeper trainings

  • Coordination of early intervention and assessment services, including screenings

  • Providing referrals

  • Receiving referrals

  • Collaborating to develop a timely referral response system

  • Improving follow-up of youth identified to be at risk for suicide and continuity of care

  • Sharing resources (funding, staff, materials, space, etc.)

  • Sharing information

  • Creating policies and protocols

  • Implementing or promoting culturally responsive treatment and prevention services for youth at risk for suicide

  • Diverting suicidal youth from emergency departments to other appropriate crisis intervention programs or services

  • Coordination of post-suicide intervention services, care, and information

  • Other, please specify

5

[FOR EACH PARTNER TYPE SELECTED UNDER 3]

Please indicate the date(s) of partnership implementation. Select the most specific date(s) as relevant.

  • MM_DD_YY to MM_DD_YY

  • Ongoing since the beginning of the grant

  • Ongoing based on a long history collaborating with this partner

  • Other, please specify

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.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

7

[FOR EACH PARTNER TYPE SELECTED UNDER Q3]

Was this partnership implemented as intended based on your work plan?

  • Yes

  • No

Please explain: __________________________


STRATEGY 10. DIRECT SERVICES

Mental Health-Related Services

Q Num

Question


Response Options



1

Name of service: ____________________



2

Please indicate the date(s) of mental health service implementation. Select the most specific date(s) as relevant for this service.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the location(s) of service implementation. Select the most specific location(s) as relevant for this mental health-related service.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


4

Type of service. Select all that apply.

  • Assessment services (e.g., a clinical assessment resulting from an early identification activity or referral)

  • Counseling services

  • Family support services

  • Evidence-based practice or treatment, please specify: ___________________

  • Other, please specify:


5

Please provide a brief description of the service including any evidence-based practices (including treatments or services) delivered:



6

Does the service involve the use of technology (e.g., social media, chat, text messaging, innovations)?

  • Yes

    • Please describe technology used_____________

  • No


7

Have these services been implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: ________________


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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the location(s) of postvention service implementation. Select the most specific location(s) as relevant.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


4

Please provide a brief description of the service:



5

Does the service involve the use of technology (e.g., social media, chat, texting)?

  • Yes

    • Please describe technology used_____________

  • No


6

Was this service implemented as intended based on your work plan?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A



3

Please indicate the location(s) of case management services. Select the most specific location(s) as relevant.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


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)?

  • Yes

    • Please describe technology used_____________

  • No


6

Was this service implemented as intended based on your work plan?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the location(s) where crisis response services were implemented. Select the most specific location (s) as relevant

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

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)?

  • Yes

    • Please describe technology used_____________

  • No

6

Was this service implemented as intended based on your work plan?

  • Yes

  • No

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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the location(s) where follow-up services have been provided. Select the most specific location(s) as relevant.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

4

Please provide a brief description of the service.


5

What strategies do you use to follow-up with youth after identification?

  • Letter

  • Email

  • Postcard

  • Home visit

  • Phone call

  • Text message

  • Social media

  • Other mode or technology, please describe: _____________

6

When is this service utilized?

  • After identification by trained gatekeepers

  • After identification by screening

  • After Emergency Department discharge

  • Other, please specify

7

Please indicate the settings where follow-up services are utilized. Select all that apply.

  • Child welfare

  • Education (K-12)

  • Emergency response

  • Higher education (college/university)

  • Juvenile justice/Probation

  • Law enforcement

  • Mental Health

  • Primary health care (other than mental health)

  • Substance abuse treatment

  • Tribal services/Tribal government

  • Other community settings

  • Don’t know

  • Refused

  • : ____________

8

Was this service implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________


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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the location(s) where traditional healing practices have been implemented. Select the most specific location as relevant to your approach.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)


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)?

  • Yes

    • Please describe technology used_____________

  • No


6

Was this traditional healing practice implemented as intended based on your work plan?

  • Yes

  • No

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?

  • Yes (continue to question 2.)

  • No

  • I don't know

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.

  • Letter

  • Email

  • Postcard

  • Home visit

  • Phone call

  • Text message

  • Social media

  • Other mode or technology, please describe: ____________

4.

What is a typical length of time between a youth being discharged from the emergency department and initiation of caring contacts?

  • Within 24 hours of discharge

  • Within 48 hours of discharge

  • Within 1 week of discharge

  • Within 2 weeks of discharge

  • Within 1 month of discharge

  • No typical length

  • Other, please specify: __________

5.

How often are caring contacts provided following a youth's discharge from the emergency department?

  • Monthly

  • Weekly

  • Periodically, no regular schedule

  • Other: _________________________________

6.

For how long are caring contacts provided following a youth’s discharge from the emergency department?

  • One month

  • Three months

  • Six months

  • One year

  • Other: ____________________________

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.

  • Grant program staff

  • Mental health agency staff

  • Hospital staff

  • Other staff, please specify: __________________

8.

Is your program implementing an approach to supporting caring contacts for youth after emergency department discharge as intended based on your work plan?

  • Yes

  • No, please explain: __________________________



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?

  • Yes (Continue to question 2.)

  • No

  • I don't know


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.

  • Letter

  • Email

  • Postcard

  • Home visit

  • Phone call

  • Text message

  • Social media

  • Other mode or technology, please describe: ____________


4.

What is a typical length of time between youth being discharged from the emergency department and initiation of follow-up?

  • Within 24 hours of discharge

  • Within 48 hours of discharge

  • Within 1 week of discharge

  • Within 2 weeks of discharge

  • Within 1 month of discharge

  • No typical length

  • Other, please specify:


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.

  • Emergency department staff responsible for tracking and monitoring follow-up

  • Grant staff responsible for tracking and monitoring follow-up

  • Mental health agency staff responsible for tracking and monitoring follow-up

  • Other staff, please specify: __________________


6.

Is your program supporting follow up with youth after emergency department discharge as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________




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?

  • Yes (Continue to question 2.)

  • No

  • I don't know

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.

  • Letter

  • Email

  • Postcard

  • Home visit

  • Phone call

  • Text message

  • Social media

  • Other mode or technology, please describe: ____________

4.

What is the length of time between a youth being discharged from inpatient hospitalization and initiation of caring contacts?

  • Within 24 hours of discharge

  • Within 48 hours of discharge

  • Within 1 week of discharge

  • Within 2 weeks of discharge

  • Within 1 month of discharge

  • No typical length

  • Other, please specify: __________

5.

How often are caring contacts provided following a youth's discharge from the inpatient hospitalization?

  • Monthly

  • Weekly

  • Periodically, no regular schedule

  • Other: _________________________________

6.

For how long are caring contacts provided following a youth’s discharge from inpatient hospitalization?

  • One month

  • Three months

  • Six months

  • One year

  • Other: ____________________________

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.

  • Grant program staff

  • Mental health agency staff

  • Hospital staff

  • Other staff, please specify: __________________

8.

Is your program supporting caring contacts for youth after inpatient hospitalization discharge as intended based on your work plan?

  • Yes

  • No, please explain: __________________________



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?

  • Yes (continue to question 2.)

  • No

  • I don't know

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.

  • Letter

  • Email

  • Postcard

  • Home visit

  • Phone call

  • Text message

  • Social media

  • Other mode or technology, please describe: ____________

4.

What is a typical length of time between youth being discharged from the inpatient hospitalization and initiation of follow-up?

  • Within 24 hours of discharge

  • Within 48 hours of discharge

  • Within 1 week of discharge

  • Within 2 weeks of discharge

  • Within 1 month of discharge

  • No typical length

  • Other, please specify:

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.

  • Emergency department staff responsible for tracking and monitoring follow-up

  • Grant staff responsible for tracking and monitoring follow-up

  • Mental health agency staff responsible for tracking and monitoring follow-up

  • Other staff, please specify: __________________

6.

Is your program supporting follow up with youth after inpatient hospitalization discharge as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________



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.

  • MM_DD_YY

  • Month

  • MM_DD_YY to MM_DD_YY

  • Ongoing

  • N/A


3

Please indicate the location(s) where this strategy was implemented. Select the most specific location(s) as relevant.

  • ZIP code(s) (up to 10 ZIP codes)

  • County or counties (up to 10 counties)

  • State (allow for state selection)

  • N/A


4

Type of suicide prevention strategy.

  • Inclusion of suicide prevention content into curriculum/course

  • Congressional Testimony or advocacy work

  • Cultural sensitivity training. Describe group: ____________________

  • Postvention Training, please specify: ____________________

  • Other training, please specify: ____________________

  • Other, please specify


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)?

  • Yes

    • Please describe technology used_____________

  • No


7

Does this strategy place emphasis or focus on any of these current priority populations? Select all that apply.

  • American Indian/Alaska Native

  • Survivors of suicide

  • Individuals who engage in nonsuicidal self-injury

  • Suicide attempters

  • Individuals with mental and/or substance abuse disorders

  • Lesbian, gay, bisexual, and transgender (LGBTQ+) populations

  • Veterans, active military, or military families

  • Hispanic or Latino population

  • Transition age youth (aged 18–24)

[If selected] Are youth connected to school or related systems?

    • Yes

    • No

  • No

  • Other, please specify


11

Was this suicide prevention activity implemented as intended based on your work plan?

  • Yes

  • No

  • Please explain: __________________________



Budget

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.

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