SBHF Data Abstract SBHF Data Abstraction Campus

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

Att I. SBHF Data Abstraction (Campus) Dec2015

Project Evaluators - Campus

OMB: 0930-0286

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OMB No. xxxx-xxxx

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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 40 minutes 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.

Garrett Lee Smith (GLS) National Outcomes Evaluation

Campus Suicide Prevention Programs

Shape1

Instructions:

Please answer each question below to the best of your ability. For assistance, please contact the data collection liaison.

During the year 1 (baseline) administration, you will submit data separately for five academic years (AYs)—the current/most recent AY and the four previous years. For the purpose of this data collection, an academic year includes fall and spring semesters.

Throughout the survey, you will be asked to report whether the information is based on tracked information or an estimate. Tracked information should be reported if it is being supplied from a comprehensive, campus-wide reporting system

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.

Student Behavioral Health Form (SBHF)

SECTION 1. CAMPUS DEMOGRAPHICS

The following information will be pre prefilled with Integrated Postsecondary Education Data System (IPEDS) data.

Total student body enrollment:

Freshman retention:

Are you reporting on an entire academic year?

  • Yes

  • No

How are you defining an academic year?

______________________________________________________________________________________________

SECTION 2. BEHAVIORAL HEALTH SERVICES ON CAMPUS

  1. If a student is in need of behavioral health services (e.g., mental health and substance use), what resources are available through your campus?

Select all that apply. If you select “None” do not select any other items from the list.

  • Behavioral health services or on-campus emergency services

  • Spiritual or religious counseling

  • Referral to an off-campus provider/emergency department

  • Transportation to off-campus provider/emergency department

  • Other, please specify: ___________________________________

  • None



  1. [IF “BEHAVIORAL HEALTH SERVICES OR ON-CAMPUS EMERGENCY SERVICES” IS SELECTED FOR Q1, ASK THE FOLLOWING]

Do you have an electronic health record system or management information system on campus to track behavioral health services (e.g., Titanium)?

  • Yes

  • No

    1. [IF NO TO 2] How is information about behavioral health services tracked? _____________________________________


    1. [IF NO TO 2] How is information about crisis services tracked? ________________________________________________



  1. [IF “BEHAVIORAL HEALTH SERVICES OR ON-CAMPUS EMERGENCY SERVICES” IS SELECTED FOR Q1, ASK THE FOLLOWING]

During the AY, how many students received behavioral health services (e.g., health or substance use) from the counseling center or other campus location?

Total number of students (unduplicated) _______

Tracked Estimate

  • Information not available




SECTION 3. SCREENINGS AND ASSESSMENT OF RISK

  1. Are students being screened/assessed for risk of suicide on campus (e.g., asking students about suicide or depression)?

Yes No Unknown



    1. How many students were screened over the course of the AY? ______ (unduplicated)

Tracked Estimate Information not available

    1. [IF YES TO 4] Are you implementing universal screenings or are there specific criteria for screening the following? Select all that apply

  • All students entering the counseling center

  • All students entering the health/wellness center (including physical health)

  • All students with an identified behavioral health concern (e.g., referred by faculty)

  • All freshmen or first year students

  • Other, please specify: _________________________________



    1. [IF YES TO 4] Is the screening conducted through informal means (e.g., asking a student if he or she is suicidal) or using a standardized screening tool?

  • Formal (e.g., a structured instrument)

  • Informal

  • Informal and formal

  • Unknown

      1. [IF “FORMAL” OR “INFORMAL AND FORMAL” ARE SELECTED] What instrument(s) are you using? Select all that apply

  • Ask Suicide Screening Questions (asQ)

  • Behavioral Health Screen (BHS)

  • Columbia Suicide Severity Rating Scale (CSSR-S)

  • Counseling Center Assessment of Psychological Symptoms (CCAPS)

  • Patient Health Questionnaire (PHQ-9)

  • Suicide Assessment Five Step Evaluation and Triage (SAFE-T)

  • Suicide Behaviors Questionnaire (SBQ-R)

  • Other, please specify: _______________________________________

    1. [IF YES TO 4] During AYXX how many students were identified as at risk of suicide according to your local procedures for identifying risk?

Total number of students who scored positive: ______

Tracked Estimate

      • Information not available

[IF 4 IS “NO” OR “UNKNOWN”, PROCEED TO Q14]

SECTION 4. SERVICES FOR STUDENTS AT RISK FOR SUICIDE (IDENTIFIED THROUGH SCREENING)

  1. Of the students who were identified through screening as at risk for suicide during AYXX (those identified in 4d), how many students received behavioral health (e.g., mental health and substance use) or crisis services on campus? (Unduplicated count of students): _____

Tracked Estimate



  • Information not available [PROCEED TO QUESTION 7]

  • None, students are referred off-campus [PROCEED TO QUESTION 9]



  1. [SKIP IF ANSWER TO Q5 IS “NONE”] Of the students identified as at risk for suicide and receiving on campus behavioral health services, how many students are referred from the following sources?

    1. Self-referral _______ Tracked Estimate

    2. Peer/student or resident advisor (RA) _______ Tracked Estimate

    3. Campus health services ________ Tracked Estimate

    4. Other faculty/ staff _______ Tracked Estimate

    5. Parent or family member ________ Tracked Estimate

    6. Other _______ Tracked Estimate


  • Information not available



  1. [SKIP IF ANSWER TO Q5 IS “NONE”] Of the students at risk for suicide who received behavioral health services on campus (in Q5), how many students received each of the following services on campus? Enter zero if this service is not conducted on campus. If this service is offered, but the number is not available, select “We offer, but number not available”

    1. Behavioral health counseling (e.g., mental health or substance use): _______ Tracked Estimate

We offer, but number not available

    1. Medication management/psychiatric services ______ Tracked Estimate

We offer, but number not available

    1. Crisis/emergency services (e.g., transportation to the emergency department) Tracked Estimate

We offer, but number not available

    1. Initiation of an on-campus emergency protocol (e.g., lethal means restrictions):_____ Tracked Estimate

We offer, but number not available



  1. [SKIP IF ANSWER TO Q5 IS “NONE”] Are suicide-specific services (a service that directly addresses suicidality rather than just underlying conditions such as depression) offered on campus? If services are not tracked, but suicide-specific services are provided, select Yes to 8 and “Information not available” for 8a.

  • Yes No

  • Unknown

    1. [IF YES TO Q8] How many students identified in question 5 received suicide-specific services? (Unduplicated count of students, not services): _____

  • Tracked Estimate Information not available


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  1. How many students identified through screening as at risk for suicide were referred to an off-campus provider for behavioral health or crisis services? (unduplicated count) ______

  • We refer students, but the number is not available

  • None, we don’t refer students to off-campus facilities





  1. [IF Q9 >0 OR “WE REFER STUDENTS, BUT THE NUMBER IS NOT AVAILABLE”] Do you follow up with students after they have been referred to an off-campus facility?

  • Yes, at least some

  • No

  • Unknown



  1. [IF YES TO Q10] Approximately what percentage of referrals made have been followed up? ____

Tracked Estimate

  • Information not available



11a. [IF Q11 IS LESS THAN 100%] If not all referrals are followed-up, what are some of the common barriers preventing follow-up? Select all that apply.

  • No staff availability to follow-up

  • Student is no longer enrolled at the institution

  • No contact information availability

  • Staff was unable to reach the student/ the student never responded

  • Other, please specify: _______________

  1. Of students who were identified as at risk of suicide (through screenings), what is your approach or set of procedures for determining whether or not someone poses high or imminent risk of suicide?

Select either Always, Sometimes, Never for the list of procedures below.




Always

Sometimes

Never

Don’t Know

Implement level of risk assessment tool (separate from previously mentioned screening instruments)





Assess suicide thoughts, plans, and intent





Assess history of suicide attempts





Assess family history





Assess nonsuicidal self-injury





Assess presence of serious mental illness





Assess availability of means for attempting suicide





Assess presence of depression and/or hopelessness





Assess presence of substance abuse





Ask student to articulate or list reasons for living





Ascertain if the student can agree to a safety contract





Try to develop safety plan with student





Meet with student’s parents or guardians to address concerns and safety issues





Immediately refer the student to speak to a clinician





Other procedure for determining someone who poses high or imminent risk of suicide, please specify: ___________________________________








  1. Using your local risk assessment processes described in Q12, for students who are identified at high or imminent risk, what are your typical procedures for managing these students? Do you typically engage in any of the following practices?

Select either Always, Sometimes, Never for the list of procedures below.


Always

Sometimes

Never

Don’t Know

Call or meet with parents or guardians to discuss monitoring





Call or meet with parents or guardians to provide education about the need for follow-up treatment





Assess safety in the home or residential facility and discuss safety with relevant parties(e.g., removing means of suicide such as firearms)





Discuss alternative ways of coping with distress, or alternatives to suicide with the student





Discuss reasons for living with the student





Work with student to identify individuals the student can contact if feeling suicidal





Refer student to off-campus emergency department or provider





Provide an after-hours emergency contact number to student





If a new referral is given, follow up with the suicidal student and family to see if they followed through with treatment recommendation or need assistance with this





Follow up with the student at school to assess ongoing status/risk





Provide student with national suicide hotline or other crisis hotline phone information





Notify the dean or other faculty





Contact the student’s RA





Administrative case review to discuss at-risk student (eg. BIT Team)





Student is removed from campus for an extended period of time





Student must be monitored by RA or other campus staff





Student is required to attend regular counseling sessions





Other, please specify:








  1. Do you provide any postvention services on campus (following a suicide attempt or completion)?

  • Always

  • Sometimes

  • Never

  • Unknown

    1. [IF ALWAYS OR SOMETIMES TO Q13] What postvention services are available on campus? Select all that apply.

  • Community/campus support services

  • Group or individual support services

  • Peer support groups

  • Family support services

  • Other: ________________________

SECTION 5. SUICIDE ATTEMPTS AND COMPLETIONS

  1. During the AY, how many suicide attempts occurred among students who lived on or off campus?

Total

Gender Tracked Estimate

Male: ___

Female: ____

Transgender: _____

Gender unknown or not tracked: ____


Age Tracked Estimate

16–20: ____

21–24: ____

>24: ____

Age unknown or not tracked: ____


  • Information on number of suicide attempts is not available

    1. What source of information did you use to answer these questions?

Select all that apply.

  • Electronic health record system

  • Grant staff tracking (e.g., Excel spreadsheet)

  • On-campus police

  • Community police

  • Local hospital

  • Emergency medical technician (EMT) or other first responder

  • Dean’s office

  • Academic department (e.g., social work or psychology staff)

  • Residential life staff

  • Campus-wide incident reporting protocol

  • Newspaper or social media

  • Other, please specify: ________________________


    1. What are your formal campus policies or protocols for a student who has attempted suicide?

Select all that apply.


Always

Sometimes

Never

Student is removed from campus for an extended period of time




Student must be monitored by RA or other campus staff




Student is required to attend regular counseling sessions




Administrative case review to discuss student




Student is referred to counseling services




No policy




Other, please specify:_________________________





  1. During the AY, how many suicide completions occurred among students who lived on or off campus?

Total

Gender Tracked Estimate

Male: ___

Female: ____

Transgender: _____

Gender unknown or not tracked: ____

Age Tracked Estimate

16–20: ____

21–24: ____

>24: ____

Age unknown or not tracked: ____


  • Information on number of suicide completions not available

    1. What source of information did you use to answer these questions? Select all that apply.

  • Electronic health record system

  • Grant staff tracking (e.g., Excel spreadsheet)

  • On-campus police

  • Community police

  • Local hospital

  • EMT or other first responder

  • Dean’s office

  • Academic department (e.g., social work or psychology staff)

  • Residential life staff

  • Campus-wide incident reporting protocol

  • Newspaper or social media

  • Vital statistics

  • Obituaries

  • Other, please specify: ________________________


Campus Student Behavioral Health Form (SBHF) Page 1

12/2015

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