RNS StateTribal RNS StateTribal

OMB No: xxxx-xxxx

Expiration Date:

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-0286.  Public reporting burden for this collection of information is estimated to average 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

State/Tribal Suicide Prevention Program

Referral Network Survey (RNS)

Description of Participation: The survey asks about your organization’s involvement in your local suicide prevention referral network (we are contacting all organizations in the local referral network). This survey is being conducted to better understand the early identification and referrals of youth at risk for suicide in your community. Participation is completely voluntary and you can exit from the survey at any time or refuse to answer any question.

Rights Regarding Participation: Your input is important; however, your participation in this survey is completely voluntary. There are no penalties or consequences to you or your organization for not participating. You can choose to stop the survey at any time, or not answer a question, for whatever reason. If you stop the survey, at your request, we will destroy the survey. You may ask any questions that you have before, during, or after you complete the survey.

The survey will take approximately 40 minutes

Privacy: All responses will be kept completely confidential. Contact information will be entered into a password-protected database which can only be accessed by a limited number of individuals (selected ICF staff) who require access. These individuals have signed confidentiality, data access, and use agreements. Your name will not be used in any reports, but it is possible that your agency and/or organization and the information you provide about your agency or organization may be identifiable when reporting results.

Benefits: Your participation will not result in any direct benefits to you. However, your input will help to provide a better understanding of the systems and networks in place to help youth identified at risk for suicide in your community. The findings will assist in informing the Substance Abuse and Mental Health Services Administration (SAMHSA) about suicide prevention activities and network processes.

Risks: This survey poses few, if any, risks to you and/or your organization. However, it is possible that your agency and/or organization and the information you provide about your agency or organization may be identifiable when reporting results.

Contact information: If you have any concerns about completing this survey or have any questions about the study, please contact Christine Walrath, principal investigator, at (212) 941-5555 or [email protected].

Please click the "I CONSENT" box below to proceed to the survey.

• I CONSENT

• I DO NOT CONSENT

Organization

1. What is the primary classification for your agency or organization? (Select only one.)

• Mental health/behavioral health agency

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

• K-12 school

• Juvenile justice agency

• Police/Law enforcement agency

• State health department agency

• Local health department agency

• Primary care providers

• Crisis center

• Tribal health agency

• Tribal social service agency

• Tribal government

• College or university

• Nonprofit community service organization

• Individual therapist

• Religious or spiritual organization

• Other, please specify:

• Not applicable

2. About how many staff members (full-time and part-time) are employed by your organization? If you are the only employee, indicate 001.

__ __ __ Number of staff members

• Don’t know

• Refused

3. What are the services available from your organization for youth who have attempted or are at risk of suicide? (Select all that apply.)

	Emergency services			Family therapy
	Safety planning			Inpatient or residential services
	Mental health assessment			Support groups
	Substance use assessment			Provide referrals to direct services
	Mental health counseling			Other services, please specify:
	Substance abuse counseling			Don’t know
	Medication management			Not applicable
	Individual therapy

3a. [IF 3 IS 01-11 (Emergency services through Support groups)]

Within the last year, approximately how many suicidal youth have been evaluated and/or treated at your organization?

• None

• One

• 2 to 10

• 11 or more

• Don’t know

• Not applicable

4. Does your organization provide training/crisis education opportunities related to suicide prevention for the staff?

   • Yes

   • No

   • Don’t know

   • Not applicable

   
   

5. How frequently are training/ crisis education opportunities related to suicide prevention made available to the staff?

• Never

• Rarely (less than once a year)

• Sometimes (1 to 3 times a year)

• Frequently (more than 4 times a year)

• Don’t know

• Not applicable

Respondent

6. What is your primary professional role? (Select only one)

   • Social worker

   • Licensed Marriage and family therapist

   • Clinical or counseling psychologist

   • Medical doctor/ Primary physician

   • Nurse

   • School psychologist

   • Guidance counselor/ School counselor

   • Teacher

   • Principal

   • Other school staff

   • Volunteer

   • Law enforcement officer

   • Probation officer

   • Religious or spiritual leader

   • Management

   • Tribal Leader

   • Other, please specify:

   • Not applicable

7. What is your highest level of education?

   • High school

   • Two-year college or technical program

   • Bachelor’s level

   • Master’s level

   • Doctoral level

   • Not applicable

8. Are you the primary point of contact at your organization that is familiar with the organizational response to youth at risk for suicide?

Yes [Go to 9]
No [Continue to 8a]
Don’t know [Continue to 8a]
	8a. [IF NO or DON’T KNOW] Do you feel that you are the appropriate person at your organization to complete this survey? Yes [Go to 9] No [Continue to 8b] 8b. [IF NO] Please provide the name, telephone number, and email address of a person at your organization who is responsible for addressing the needs of youth identified at risk for suicide. Name: _______________________ Telephone Number: _____________ Email: ________________________

[IF NO TO 8a, DO NOT PROCEED]

Professional Development

9a. Within the last year, approximately how many training/ crisis education opportunities have you participated in (either at your organization or at an external organization)?

	0
	1-2
	3-5
	6-10
	11+
	Don’t know
Not applicable

9b. Throughout your training and career, approximately how many suicidal youth have you evaluated and/or treated? Please respond based on your overall career, not just your tenure at the agency where you are currently employed.

• 0

• 1-2

• 3-5

• 6-10

• 11+

• Don’t know

• Not applicable

Referral Networks

The following organizations have been identified as part of your county level referral network for youth at risk or identified as at risk. Please check all of the organizations that you consider part of your immediate referral network (these should be organizations that you either make referrals to or receive referrals from).

[THIS WILL BE PREFILLED BASED ON THE AGENCIES THAT ARE IDENTIFIED THROUGH SNOWBALL SAMPLING TO BE PART OF THE NETWORK]

• Agency A

• Agency B

• Agency C

[THE FOLLOWING TABLES WILL BE PREFILLED WITH ONLY THE AGENCIES THAT ARE IDENTIFIED ABOVE AS BEING PART OF THE PRIMARY REFERRAL NETWORK]

For those agencies that you identified as part of your immediate referral network, which of the following are the primary aspects of your relationship? (Check all that apply.)
	Providing referrals	Receiving referrals	Coordination of gatekeeper trainings	Sharing resources (funding, staff, materials, space, etc.)	Sharing information	Creating policies and protocols	Other (please specify)	None
Agency A							__
Agency B							__
Agency C							__

For those agencies that you identified as part of your immediate referral network, please rate the overall effectiveness of the collaboration.
Agency	Effectiveness
	Very Ineffective	Ineffective	Neutral	Effective	Very Effective	Do not know	Not Applicable	Approximately how many years have you or your organization maintained a relationship with this agency?	Do you have a formal system in place for sharing information?
Agency A
Agency B
Agency C

Which of the following do you consider barriers to maximizing the potential efforts of your referral network? (Check all that apply.)

Lack of protocols and policies

Lack of cooperation between organizations

Lack of resources (funding, staff, materials, space, etc.)

Lack of information about other resources in the community

Lack of knowledge about suicide prevention services

Competition among service providers to meet internal goals and targets

Staff turnover

Other (please specify)

Not Applicable

Agency A

_________

Agency B

_________

Agency C

_________

For those agencies you identified as part of your immediate referral network, please provide us with information about the number of referrals and follow-ups over the last 6-month period (these may be based on tracked numbers or estimates).

Total number of individuals referred to

Total number of individuals referred from

Do you follow-up with youth after they have been referred to another agency?

If yes to C, approximately what percent of referrals made have been successfully followed-up?

If yes to C, are these numbers based on tracked numbers or estimates?

If no referrals have been made/received, indicate 0

Do not use a percent sign

Agency A

Yes No Sometimes Don’t know Not applicable

Tracked Estimate

Agency B

(Same as above)

(Same as above)

Agency C

(Same as above)

(Same as above)

14. Are assessments of risk conducted onsite?

• Yes [Continue to 15]

• No [Skip to 22]

• Don’t know [Skip to 22]

[IF YES TO 14] Are you aware of formal policies, protocols or guidelines (written or communicated otherwise) at your agency regarding:
	Yes	No	Don’t know
Assessment of youth risk
Addressing the needs of youth who attempt suicide and their families
Following up with (or tracking) youth who are identified as seriously at risk or who have attempted suicide	[Continue to 15ci & 15cii]	[Skip to 15D]	[Skip to 15D]

15ci. How long do you typically try to continue following-up with youths identified as at risk or as having made a suicide attempt?

• Next day

• 1 week or less

• Up to 1 month

• Up to 3 months

• Up to 9 months

• 1 year or longer

• No typical length

• Don’t know

• Not applicable

15cii. What strategies do you use to follow-up with youth identified as “at-risk” or as having made a suicide attempt? [Select all that apply]

• Phone calls

• Text messages

• Letter

• Email

• Home visit

• Don’t know

• Not applicable

CONTINUED [IF YES TO 14] Are you aware of formal policies, protocols or guidelines (written or communicated otherwise) at your agency regarding:
	Yes	No	Don’t know
A designated person who makes decisions in a crisis situation
Provisions of how referrals and follow-ups are documented

When reflecting on your current protocol for the following, do you think efforts are not enough, just right or too much:
	Not enough	Just right	Too much	Don’t know
Risk assessment
Follow-up protocol
Supporting families/youth

14. What is your approach or set of procedures for determining whether or not someone poses high or imminent risk of suicide? (Check all that apply.)

• Assess suicide thoughts or plans

• Assess suicidal intent and whether the youth believes s/he can refrain from attempting suicide

• Assess history of suicide attempts

• Assessment of family history

• Assessment of non-suicidal self-injury

• Assess availability of means for attempting suicide

• Assess presence of depression and/or hopelessness

• Assess presence of substance abuse

• Ask youth to articulate or list reasons for living

• Ascertain if the youth can agree to a safety contract

• Try to develop safety plan with youth

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

• Immediately refer the youth to speak to a clinician at a referral agency

• Other procedure for determining someone who poses risk of suicide, please specify:

• Don’t know procedure for determining someone who poses risk of suicide

• Not applicable procedure for determining someone who poses risk of suicide

14. For youth identified as high risk, what are your typical procedures for managing these youth? Do you typically engage in any of the following practices? (Check all that apply.)

• 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 and discuss safety in the home with parents/guardians (e.g., removing means of suicide such as firearms)

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

• Discuss reasons for living with the youth

• Ask youth to agree to a signed no-suicide contract or promise

• Work with youth to identify individuals the youth can contact if feeling suicidal

• Refer youth to the emergency department or crisis service

• Refer youth to a community provider if the youth / family is/are not already in treatment

• Provide an after-hours emergency contact number to youth

• Provide an after-hours emergency contact number to parents / guardians

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

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

• Provide youth with national suicide hotline or other crisis hotline phone information

• Follow up to see if they kept appointment

• Other, please specify:

____________________________________________________________________________________________________________________________________

• Don’t know

• Not applicable

14. What happens when your organization identifies someone at elevated risk for suicidal behavior, or someone that has made a suicide attempt through suicide prevention programs? (Select all that apply.)

• Referral to mental health professional within the school system (e.g., school social worker or guidance counselor) that has responsibility for the school or agency

• Referral to emergency room (for evaluation of all youths identified)

• Referral to emergency room for select cases

• Referral to mental health provider in the community

• Contact parents/guardians to let them know of the young person’s status (and possibly suggest evaluation and/or treatment)

• Conduct an in-house clinical assessment

• Other, please specify:

____________________________________________________________________________________________________________________________________

14. Once a youth is identified as potentially at risk or as having made a suicide attempt, how long is it usually before someone (either within your organization or within your referral network) can meet with him/her to do a clinical assessment? (Please choose the option that best describes what usually happens.)

• Immediately

• Less than 2 hours

• Less than 4 hours

• Within the school day

• Within 2 school days

• Within a week

• Longer than a week

14. What are the factors that affect the length of time between identification and clinical assessments? (Select all that apply.)

• Recent suicide attempt

• Level of risk

• Demographic characteristics

• Clinician availability

• Insurance or other funding consideration

• Other, please specify:

________________________________________________________________________________________________________________________________________________

• Don’t know

• Not applicable

14. Have you had any direct contact with [GRANTEE NAME]?

• Yes [Continue with 22a and 22b]

• No [Skip to 23]

• Don’t Know Skip to 23]

22a. [IF YES TO 22] Have you received any gatekeeper trainings through [Grantee name]?

• Yes

• No

• Don’t know

22b. [IF YES TO 22] Select all of the activities that are primary to your relationship with [GRANTEE NAME]?

• Providing referrals to the organization

• Receiving referrals from the organization

• Coordination of Gatekeeper trainings

• Sharing resources

• Sharing information

• Creating policies and protocols

• Other, please specify:

• Not applicable

14. Identify any barriers or challenges faced by your referral network.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14. Identify any strategies you have utilized to strengthen the network.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Referral Network Survey Page 1

12/2015