BRFSS Crisis Protocol for Sensitive Questions

Attachment 14: BRFSS Crisis Protocol for Sensitive Questions

Crisis Protocol

Step 1: Recognize that a respondent is possibly distressed.

Signs that a respondent is possibly in crisis:

• Hesitancy to answer a question or questions;

• Refusal to answer questions or to continue the interviewing process;

• Lowering of the volume or tone of his/her voice;

• Responding in an agitated manner by raising his/her voice or using inappropriate language;

• Crying;

• Indications of tremors, a quavering in the respondent's voice;

• Disorganization, dissociation, or non-responsiveness to questions asked.

Step 2: Assess the level of distress that a respondent is apparently experiencing.

Below is a table that provides the some guidance to you as to what indicators you might become aware of on the telephone indicating that a person is in distress or approaching a crisis.

Level of Distress	Signs or Indicators of Distress
Level 1 : Minimal	Change in voice tone or volume. Changes in focus. Hesitancy to answer questions.
Level 2: In-Need of Referral	Level 1 signs plus any of the following: Displays an unwillingness or hesitancy to continue. Sobbing, weeping, and/or crying on the telephone. Displays other obvious signs of agitation.
Level 3: Immediate Help	Includes a combination or all of the signs for Level 1 and/or Level 2 plus the following: Respondent openly states the intention to hurt her/himself. Respondent openly states his/her intention to hurt other people. Respondent openly asks for help.

Step 3: Respond appropriately to the situation.

Based on your assessment of the level of distress it is imperative that you react appropriately and with sensitivity.

Distress Level	Interviewer Actions	Supervisor Actions	Project Management Actions
Level 1	Assess where you are in the questionnaire and ask respondent if it is ok to continue: “Is it ok to continue?“ Depending on how s/he answers and where you are in the questionnaire you may do the following: Yes - Continue with sensitivity. Yes, but not now : Are you in the Adverse Childhood Experiences section? If no, Suspend, and offer the 1-800 number (s) from your help screen . Record the masterid and alert your supervisor. If you are in the Adverse Childhood Experiences section. Do not offer to call back later—for these sections if respondent does not want to continue, please offer the hotline number and offer to connect the respondent to the hotline (based on crisis level). Record masterid, alert your supervisor. Suspend and disposition as 169 “Respondent ended interview due to distress” Sections Record masterid and Alert your supervisor. No, don’t want to continue ever – terminate and thank. Write “DO NOT CALL BACK” in message field and alert supervisor. Use disposition as 169 “Respondent ended interview due to distress” Hangs up – suspend with a note about the situation and alert supervisor.	If needed: Come over to the interviewer and be prepared to help out by connecting or doing a hot transfer to the hotline. Supervisor is alerted for all interviews that terminate or result in a hang-up after the offer of a break. Supervisor will get the masterid for the case and will inform the project managers about the situation – date, time, and a detailed description of the interaction between the interviewer and the respondent, including the survey question at which it occurred.	Project Managers review the case and possibly follow-up with the supervisor and interviewer for more information. Project Management decides if any follow-up calls are made to the hang-ups or terminated interviews
Level 2	Raise your hand and get a supervisor’s attention while you affirm what you hear: “I can hear that this interview is upsetting you. Would you like some help? I can provide you a phone number or connect you to someone who can help you. If the respondent says YES – refer to the hotline number in your special screen the appropriate referral (hotline number listed below) based on what the respondent seems to be upset about. If the respondent says NO, or if they say “yes” to you providing the phone number, but they don’t want you to connect them to the hotline/phone number now ask if s/he would like to continue the interview now or later (PLEASE NOTE IF THE RESPONDENT DOES NOT WANT TO CONTINUE, DO NOT SCHEDULE A CALL BACK Disposition as 169 “Respondent ended interview due to distress”): Yes - Continue with sensitivity. Yes, but not now - Suspend and schedule a callback and offer appropriate 1-800 numbers from your help screen. Record masterid and alert your supervisor No, don’t want to continue ever – terminate and thank. Write “DO NOT CALL BACK” in message field and alert a supervisor. Disposition as 169 “Respondent ended interview due to distress” Hangs up – suspend with a note about the situation, and alert a supervisor.	Come over to the interviewer and be prepared to help out by connecting or doing a hot transfer to the hotline. File an adverse event report with project management staff informing them that a referral was given, the masterid, the interviewer id, date, time, details of the interaction, if QA was listening, where it occurred in the interview, and if the appropriate protocols were followed.	Project Management reviews and files the adverse event report. This type of report is kept by project management but not forwarded to the IRB. Project Management decides if any follow-up calls are made to the hang-ups or terminated interviews.
Level 3	Raise your hand and get a supervisor’s attention. If a respondent is exhibiting level 3 crisis signs, or reporting that they want to hurt themselves: Affirm what you hear: “I can tell that this interview is upsetting you.” “I can provide you a phone number of or connect you to someone who can help you now” “I would like to stay on the line with you while my colleague calls X? OK?” Keep the person informed about what is happening, do what the respondent says. “This interview can be very stressful, and I think we should stop for now, but sometimes talking to someone can be helpful. I Can provide you a number or connect you to someone who may be able to help you now. Would you like me to give you the number, or connect you?” If the respondent says YES, provide referral telephone numbers or connect (with supervisor help) before getting off the call. If the person just asks to stop at any point, suspend with a terminal disposition 169 “respondent ends interview due to distress”, or if s/he hangs up, disposition 169 “respondent ends interview due to distress, with a note. Always record masterid and get supervisor help. If a respondent reports that they want to hurt someone else: Raise your hand and get a supervisors attention. Assess the level of risk homicide by asking the following questions with a supervisor/QA present: “Do you have a plan on how to do this?” “Do you have the means or ability to carry out your plan?” “Are you thinking of doing this now?” If respondent says yes to 3 of the above, risk of harm is HIGH. Attempt to keep respondent on phone if possible. If respondent says yes to 1-2 of the above, supervisor will help asses risk.	Come over to the interviewer and be prepared to help out by connecting/doing a hot transfer to the hotline. Signal for QA to get on the line too and take notes. Make the necessary calls/hot transfers (SEE DETAIL BELOW FOR CALLS WHEN A RESPONDENTS REPORTS WANTING TO HURT SOMEONE ELSE) If the respondent terminates the call before someone can be contacted for her, or before we can obtain her locations– call supervisor to find out whether additional calls can or should be made immediately. File an adverse event report with project management staff informing them that a referral was given, the masterid, the interviewer id, date, time, details of the interaction, if QA was listening, where it occurred in the interview, and if the appropriate protocols were followed. The form needs to be filed on that shift. If a level 3 situation is encountered call center and project management need to be called. Additional NOTE: IF A RESPONDENT REPORTS THEY WANT TO HURT SOMEONE ELSE. DO ALL OF THE ABOVE AS WELL AS THE FOLLOWING: Help in the evaluation of risk, confirm if the respondent provides 1-3 YES’s and instruct the interviewer as to what to do – Make the necessary calls to local emergency services/local 911 services, based on respondent phone number. Explain to emergency services who you are, why you are calling and that you would like a house call to ensure that the household is safe. Follow Level 3 protocol for call center management notification immediately; file and adverse event report form that shift.	Project Management reviews and files the adverse event report. Project Management debriefs with the interviewer, supervisor and QA who filed the report as soon as possible. IRB may advise about the need to change or revise protocols as a result of the event, or the appropriate follow-up to the event. Project Management implements and follows-up as directed. Project Management informs the call center staff about the outcomes of the event to the extent that they are able to and it is legally possible. If there is to be a follow-up call to the respondent, Project Management will direct the call center as to how the callback is to be made (e.g., using an interviewer with special training.)

Step 4: Document the case—Adverse Event Report Form

When a Level 2 or Level 3 situation is encountered it is necessary to document the case immediately while the event is fresh in your mind. There is an Adverse Event Form included in the training materials in Appendix 2 and available on the network and ISite for you to use for this purpose. More detail and information is better than less. This needs to be filled out on the shift in which it occurs and immediately sent electronically to project management and the hard copy sent to the Project Director, Marquisette Glass-Lewis.

The Adverse Event Report Form needs to include at a minimum the masterid, time, date, details of the event – which should include the survey question at which the event occurred – so someone else can understand why it was assessed as a level 2 or 3, and the names and signatures of the call center staff who observed the event.

It is paramount that once you think you are in a level 2 or level 3 situation that you get someone else to be listening to the call – get the floor supervisor over, get QA on the line, get the interviewer next to you too until a supervisor comes over. Everyone and anyone who listens to all of part of the interaction needs to fill out the Adverse Event Form.

Step 5: Self- Care for You

Dealing with a difficult or crisis situation on the telephone can be emotionally draining and take a toll on you. After the call is over and you have documented, take a break. And when you go home at the end of your shift – take care of yourself even more. Refer to the training manual section on self-care for more information.

Situations Involving Other Individuals

If at any time during the telephone interview you believe that someone is listening in – perhaps you hear a telephone picked-up or you hear someone breathing other than the respondent, you should stop asking questions and ask if s/he would still like to continue the interview and do what s/he says – continue, suspend and schedule a callback, suspend with providing his/her information to call in, or terminate. Leave a message as to what occurred in the interviewer notes field of the CATI program.

If you hear someone, anyone, enter the location where the respondent is participating in the interview – you should ask her/him if s/he wants to continue at another time– continue, suspend and schedule a callback, suspend with providing her information to call in, or terminate. Leave a message as to what occurred in the interviewer notes field of the CATI program.

In either of the above cases, if the situation is too complex to be adequately described in the message field, alert a supervisor (make sure you give your supervisor the masterid), who will document the situation in an email that will be sent to Project Management.

Suicide Prevention Network Helpline:

1) National Suicide Prevention Helpline: 1-800-273-TALK (8255)

Trained crisis workers are available to talk 24 hours a day, 7 days a week. Your confidential and toll-free call goes to the nearest crisis center in the Lifeline national network. These centers provide crisis counseling to individuals who are suicidal or experiencing emotional distress. Mental health referrals are also provided.

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