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Youth
Outcomes and Resiliency Survey (YORS) – (includes “extended”
modules)
Section
1: Demographics
Please answer
these demographic questions. We will use this information to
understand more about our sample, and to understand if different
groups are having different experiences. These answers are
confidential and will not be shared with anyone outside of the
evaluation team.
Participant ID
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How old are you? In years
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How would you describe your gender? Select
all that apply.
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Woman
or girl
Man
or boy
Non-binary
Genderqueer
Agender
Something
else. I identify as:_________
I
am not yet sure of my gender
I
am not sure what this question means
I
do not want to answer this question
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Do you identify as transgender?
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What sex were you assigned at birth?
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How would you describe your sexuality or
sexual orientation? Select all that apply.
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What
is your race?
Select
all that apply.
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American
Indian or Alaska Native
Asian
Black
or African American
Hispanic
or Latino
Middle
Eastern or North African
Native
Hawaiian or Pacific Islander
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What state do
you live in?
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What is your zip code?
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Section 2: Suicidality
The next set of
questions ask about thoughts about suicide and attempted suicide. We
know that it can be uncomfortable to think about or respond to these
kinds of questions, but answering truthfully will help us understand
what you, and other youth, are experiencing. We also know that
sometimes people might think that their friends or parents want them
to answer a certain way, but we are interested in what YOU have to
say. Remember, these are confidential – no one will ever know
how you responded.
In the past 30 days, did you seriously
think about trying to kill yourself?
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In the past 30 days, did you make any
plans to kill yourself?
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In the past 30 days, have you had
thoughts that you would be better off dead or would rather not
wake up in the morning?
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In the past 30 days, did you try to kill
yourself?
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In the past 30 days, have you ever had
thoughts of hurting yourself in some way but have not actually
done so?
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In the past 30 days, have you ever hurt
yourself in some way on purpose?
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In the past 30 days, did you seek support
from any of the following sources? (select all that apply)
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In the past 30 days, did you get medical
attention from a doctor or other health professional as a result
of an attempt to kill yourself?
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In the past 30 days, did you stay in a
hospital overnight or longer because you tried to kill yourself?
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Section 3: Positive Youth
Development Sustainability Scale
The following
questions are about your level of happiness and satisfaction with
different areas of life.
Please
indicate how much you disagree or agree with each of the following
statements.
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Strongly
Disagree
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Disagree
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Neutral
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Agree
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Strongly
Agree
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I
am happy at home.
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I
am happy at school.
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I
am happy with the services I am receiving.
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I
am happy with the people in my life.
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I
am satisfied with my life.
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I
feel connected to my parents.
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I
feel like I am worth something.
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When
others need help, I help them.
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It
is easy for me to know how others feel.
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I
try to encourage others when they are not as good at something
as me.
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I
can be counted on to help if someone needs me.
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I
care about the feelings of my friends.
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I
have many different types of friends.
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My
friends care about me.
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I
feel connected to my friends.
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I
feel connected to my teachers.
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I
have people in my life I look up to and admire.
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I
have close friendships.
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I
take an active role in my community.
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I
am someone who gives to benefit others.
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I
like to work with others to solve problems.
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I
have things I can offer to others.
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It
is important for me to try and make a difference in the world.
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I
have goals in my life.
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I
know what I want to be when I grow up.
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I
like to learn new things.
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I
can manage my emotions.
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It
is important for me to do the right thing.
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If
I promise to do something I can be counted on to do it.
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Section 4: Screening
Experience
The
following questions are about your recent experience being screened
for mental health or suicidality concerns.
Were you recently screened for mental
health or suicidality concerns?
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49a. Where
did this screening take place?
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49b. Were you experiencing mental health or suicidality
symptoms at the time you were screened?
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Yes
No
I’m
not sure
I
don’t remember
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49c. How did you complete the screening?
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I
was asked questions by the person conducting the screening
in-person
I
was asked questions by the person conducting the screening over
the phone
On
paper by myself
Online
or virtually by myself
Something
else:
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49d. Who was part of the conversation with you?
Select
all that apply.
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49e. How comfortable did you feel being open and honest when
responding to screening questions?
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Very
comfortable
Somewhat
Comfortable
Neutral
Somewhat
uncomfortable
Very
uncomfortable
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49f. Did you feel safe during the screening experience?
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49g. Were you asked for your own consent before being asked
screening questions?
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49h. Were you able to ask questions after the screening
process?
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Section 5: Cultural
Appropriateness of Services
Please
indicate how much you disagree or agree with each of the following
statements.
I
feel supported by the [PROGRAM/AGENCY] in expressing my…
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Strongly
Disagree
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Disagree
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Neutral
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Agree
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Strongly
Agree
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gender.
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pronouns.
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sexual
orientation.
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culture.
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beliefs.
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concerns
regarding the services.
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I
feel that the [PROGRAM/AGENCY] staff can understand my culture.
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I
feel that the [PROGRAM/AGENCY] is willing to work with me to
meet my needs. (For example, helping me to receive the services
that I know I need.)
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I
feel that the [PROGRAM/AGENCY] is willing to work with me to
meet my preferences. (For example, helping me to receive the
services that I know I want.)
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I
feel that the [PROGRAM/AGENCY] is willing to work with me to
meet my goals.
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Has the [PROGRAM/AGENCY] invited you to
provide feedback on your experience?
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Has the [PROGRAM/AGENCY] invited you to
help design programming or program materials?
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Section 6: Self-efficacy
for Accessing Information
The
following questions are about your perspective or opinion about
different types of information that are available to you.
I know how to find information that will
help me to better understand mental health.
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Yes, I know where to access
this information
No, I don’t know where to
access this information
I’m not sure
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I know how to find information that will
help me to better understand suicide
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Yes, I know where to access
this information
No, I don’t know where to
access this information
I’m not sure
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I know how to find information that will
help me to better understand substance use.
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Yes, I know where to access
this information
No, I don’t know where to
access this information
I’m not sure
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I know how to find information that will
help me to better understand recovery from a mental
health or substance use condition.
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Yes, I know where to access
this information
No, I don’t know where to
access this information
I’m not sure
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[Section
6.1 is generated for each 5th
respondent.]
Section 6.1: Self-Efficacy
for Accessing Information - EXTENDED
The
following questions are about your perspective or opinion of the
different types of information that are available to you.
I know how to find information that will
help me to better understand self-harm.
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Yes, I know where to access
this information
No, I don’t know where to
access this information
I’m not sure
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I know how to find information that will
help me to better understand trauma.
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Yes, I know where to access
this information
No, I don’t know where to
access this information
I’m not sure
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I know how to find information that will
help me to better understand general health and
well-being.
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Yes, I know where to access
this information
No, I don’t know where to
access this information
I’m not sure
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I know how to find information that will
help me to better understand sexual and reproductive
health.
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Yes, I know where to access
this information
No, I don’t know where to
access this information
I’m not sure
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Section 7: Self-Efficacy
for Accessing Services
The
following questions are about your perspective or opinion of the
different types of resources that are available to you.
I know how to find individual or group
therapy services.
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I know how to find individual or group
peer support resources.
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I know how to find help for issues in my
family.
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I know how to get connected to other
youth-specific resources in my community.
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I know how to refer a friend or sibling
for services if they need them.
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Section 8: Satisfaction and
Effectiveness
Please
answer how well the [PROGRAM/AGENCY] is meeting your needs as an
individual.
What is the primary type of
services/support you are participating in right now? Select
One
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How likely are you to continue on with it
as long as it is available to you?
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To what extent has the [PROGRAM/AGENCY]
helped you to know what to expect in services or supports, inside
or outside of the program?
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A lot
Somewhat
Not at all
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To what extent has the [PROGRAM/AGENCY]
helped you to feel safe?
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A lot
Somewhat
Not at all
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To what extent has the [PROGRAM/AGENCY]
helped you to feel hopeful?
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A lot
Somewhat
Not at all
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To what extent has the [PROGRAM/AGENCY]
helped you to build coping skills and strategies?
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A lot
Somewhat
Not at all
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[Section
8.1 is generated for each 5th
respondent.]
Section 8.1: Satisfaction
and Effectiveness - EXTENDED
Please
answer how well the [PROGRAM/AGENCY] is meeting your needs as an
individual.
To what extent has the [PROGRAM/AGENCY]
helped you to feel welcomed?
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A lot
Somewhat
Not at all
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To what extent has the [PROGRAM/AGENCY]
helped you to feel respected?
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A lot
Somewhat
Not at all
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To what extent has the [PROGRAM/AGENCY]
helped you to want to participate in services?
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A lot
Somewhat
Not at all
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To what extent has the [PROGRAM/AGENCY]
helped you to want to continue coming back for services?
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A lot
Somewhat
Not at all
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To what extent has the [PROGRAM/AGENCY]
helped you to want to find other types of helpful resources?
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A lot
Somewhat
Not at all
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To what extent has the [PROGRAM/AGENCY]
helped you to meet new people?
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A lot
Somewhat
Not at all
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Section 9: Follow-up
Service Experience
The
following questions are about your experience with referrals or
follow-up services and supports.
Were you offered any referrals to
services or other follow-up support?
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Yes [complete 87a-87d]
No [Go to 88]
I’m not sure [Go to 88]
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87a. Can you describe the referral or follow-up support that
you were offered?
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OPEN
ENDED
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87b. Has anyone followed up to help you get connected with
these referrals or other follow-up supports?
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87c. Are you planning to use these referrals or supports?
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Yes [complete 87c1]
No [ Go to 87d]
I’m not sure
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87c1. Why or why not?
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OPEN ENDED
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87d. What would help you use referrals or supports? (For
example, a ride to services, support from family or friends,
having more help from my service provider, etc.).
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OPEN ENDED
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Did you wish you were offered referrals
to something else?
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Section 10: Youth Family
Dynamics
The
following questions are about your family’s involvement in the
services/supports you receive from [AGENCY/PROGRAM].
What does your family think about mental
health services?
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Very supportive
Supportive
Neutral/Unsure
Unsupportive
Very Unsupportive
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Does your family know that you receive
services and supports for mental health and/or suicidality?
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90a. How do you think your family feels about the fact that you
are receiving services?
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OPEN
ENDED
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90b. Does your family support you in accessing services?
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90b1. What types of support does your family provide? Select
all that apply
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[Section
11 & 12 are generated for every 5th
respondent. Otherwise, go to end of survey message]
Section 11: Youth Peer
Dynamics
What do your friends/peers think about
mental health services?
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Very supportive
Supportive
Neutral/Unsure
Unsupportive
Very Unsupportive
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Do your friends/peers know that you
receive services and supports for mental health and/or
suicidality?
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92a. How do you think your family feels about the fact that you
are receiving services?
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OPEN
ENDED
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92b. Do your friends/peers support you in accessing services?
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92b1. What types of support does your friends/peers provide?
Select all that apply
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Section 12: Youth School
Environment
Are you currently attending school?
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Yes [complete 93a-93d]
No [Go to next section]
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Please rate the extent to which you agree or disagree with
the following statements.
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93a. I feel connected with my school.
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93b. I feel connected with my teachers or other school staff.
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93c. My teachers/school staff take an interest in my future, or
what happens to me after I leave school.
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93d. I am happy with my level of participation in class and
school activities.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |