EIRFT-Screening Fo EIRFT-Screening Form

OMB No. 0930-0286

Expiration Date: XX-XX-XXXX

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0286. Public reporting burden for this collection of information is estimated to average 3 hours per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Early Identification, Referral, Follow up, and Treatment Form – Screening

(EIRFT-S)

Directions: The following information should be completed by a professional to document aggregate information about youths—aged 10–24— who were screened for suicide risk as part of your GLS Suicide Prevention Program. The grantee should complete this form for both group screening events and individual screenings. In the case of individual screenings, the grantee should sum the individual screening information and provide aggregate numbers in the form below on a monthly basis. As you complete the form, please note that all entries and descriptions of other should not use acronyms or any local terms; please be sure that you only select other when none of the available response options apply and that your descriptions of other be sufficient for someone who is not familiar with your program or community to interpret.

Screening Identification (ID) Number: Unique ID created by grantee.
Date of screening
ZIP Code where screening took place
Was this a group screening event or individual screenings? (i.e., were multiple youths screened at one time as part of a screening event, or was the screening administered to one individual at a time)		Group Individual
What screening tool was used?		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) Screening Tool in Signs of Suicide (SOS) SAFE-T Patient Safety Screener (PSS-3) Locally developed screening tool Other, please specify:
Where did the screening take place?		School or school-based health clinic College or university Mental health (MH) agency (e.g., private MH provider, psychiatric hospital, outpatient clinic) Social Service agency (e.g., child welfare, supportive housing) Juvenile justice/criminal justice agency (e.g., pretrial services, mental health court) Physical health agency (e.g., primary care, pediatrician, emergency department, hospital) Community-based organization, recreation or afterschool activity (e.g., Boys & Girls club, faith-based organization) Law Enforcement Agency Other, please specify:
Was this screening virtual or in person?		Virtual In Person
Who was screened?		All youth in attendance (e.g., all youth coming to a primary care provider’s office) [Go to 10] Youth meeting particular criteria [Continue to 9a]
	Please describe the criteria used (e.g., youth with suicide attempt history, youth in high-risk demographic categories)
Please indicate the unduplicated count of number screened (i.e., the number of youth who took the screening questionnaire):
10. Please indicate the unduplicated count of number screened positive: Screen positive on the screening questionnaire and/or Self-identify at any point during the screening process

11. Please indicate the number of youths screened in the following gender categories. Numbers should sum to the total number of youth screened, since each individual screened should fall under a single gender category.

Gender	Count
Male
Female
Transgender (Male to Female)
Transgender (Female to Male)
Gender non-conforming
Other, please specify:
Information on gender is missing

11. Please indicate the number of youths screened in the following age categories. Numbers should sum to the total number of youths screened, since each individual screened should fall under one of the below age categories.

Age	Count
Under 10
10– 15
16– 20
21– 24
Information on age is missing

11. Please indicate the number of youths screened in the following single race/ethnicity categories. Numbers should sum to the total number of youths screened, since each individual screened should fall under one of the below single race/ethnicity or multiple race/ethnicity categories.

Individuals of a single race:
Race	Count
American Indian or Alaska Native
Asian
Black
Hispanic/Latino
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Other; please specify:
Individuals of more than one race:
American Indian or Alaska Native and Black or African American
American Indian or Alaska Native and White
Asian and White
Black or African American and Asian
American Indian or Alaska Native and Black or African American
American Indian or Alaska Native and White
Asian and White
Black or African American and Asian
Black or African American and White
Native Hawaiian or Other Pacific Islander and White
Individuals reporting multiple races not included above
Information on multiple races is missing

EIRFT-Screening Pre-OMB DRAFT 4.1.2023