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pdfOMB Control Number: 2900-0911
Estimated Burden: 15 minutes
Expiration Date: 08/31/2027
Thank you for agreeing to participate in this Community Opinion Survey. This survey is
aimed at all people in your community, regardless of whether you have experienced
thoughts of suicide yourself. Our goal is to learn more about the factors that affect people’s
likelihood to seek help when experiencing suicidal thoughts.
Your valued feedback helps us improve existing suicide prevention efforts and create new
programs for Veterans and other members of your community.
VA 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 29000911, and it expires 08/31/2027. Public reporting burden for this collection of information is estimated to average 15
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 and any other aspect of this collection of information, including suggestions for reducing the burden,
to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-0911 in any
correspondence. Do not send your completed Survey to this email address.
Privacy Act Statement: VA has determined this collection is not subject to the Privacy Act of 1974, and the particular
notice and other requirements of the Act do not apply. Specifically, VA will not collect information about individuals and
will not use a name or any other personal identifier to routinely retrieve records from the information collected. This
information is being collected to evaluate the effectiveness of the investment in suicide prevention for Veterans. The
results of this survey will help inform improvements in VA suicide prevention programs and determine whether the
programs and policies implemented by a community have resulted in positive change in knowledge and attitudes. Any
information you enter here is anonymous and will be kept private to the extent provided by law. All respondent contact
information is stored separately from the survey answers. Participation in this survey is voluntary, and failure to respond
will not have any impact on your entitlement to benefits.
Your participation in this confidential survey is purely voluntary. You do not have to answer
any questions that you don’t want to. Your answers will never be associated with your name
or any identifying information.
There are questions about suicide that may be upsetting to some people. If you or someone
you know is in crisis or having thoughts of suicide, please call the Suicide & Crisis Lifeline @
988 for confidential support 24 hours a day. The Veterans Crisis Line can be reached @ 988,
Press 1.
For more information, please visit communityopinionsurvey.org
For questions or if you experience technical issues, please call 1-888-913-1380 or email
[email protected]
Instructions for Completing this Questionnaire:
Please use a blue or black pen
to complete the questionnaire
You are sometimes told to skip over
some questions in this
survey. When this happens, you will
see an arrow with a note that tells
you what question to answer next,
like this:
(If Yes, go to 41a -- If No, go to 42)
Answer each question by making
an X in the box next to your
answer, like this :
1
Yes
2
No
Section A. About You
1. What is the year of your birth (y y y y)
y
y
y
y
2s. What is your sex?
1
Female
2
Male
3. Would you describe yourself as (check ALL that apply):
We collect information about race and ethnicity, including the national origin of you and/or your ancestors, so we can ensure we are
representing the full range of people within the community.
1
2
3
4
White (For example, German, Irish, etc.)
Hispanic, Latino or of Spanish origin (For
example, Puerto Rican, Cuban, etc.)
Black or African American (For example,
African American, Haitian, Nigerian, etc.)
Asian (For example, Chinese, Vietnamese,
Asian Indian, etc.)
4. Have you served in the Armed Forces?
5
Middle Eastern or North African (For example, Lebanese, Iranian, Egyptian, etc.)
6
American Indian or Alaska Native (For example, Navajo Nation, Aztec, etc.)
7
Native Hawaiian or other Pacific Islander (For example, Native Hawaiian,
Samoan, Tongan, etc.)
8
1
Other race or ethnicity (please specify)
_____________________________________________
Yes
2
No
Section B. Community Perceptions
The next set of questions is about relations in your community. 'Community' means different things to different people, so please
use whatever definition makes the most sense to you. We will begin by asking about the viewpoints of those in your community as
a whole, that is the area that you live in and the people you encounter there on a regular basis.
Please indicate your agreement with each of the following statements
about your community.
Strongly
Agree
5. Most people in my community believe that a Veteran can be trusted.
1
6. Most people in my community would not marry a Veteran.
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
2
3
4
5
1
2
3
4
5
7. Only a few people in my community believe that a Veteran is dangerous.
1
2
3
4
5
8. Most people in my community think less of a Veteran.
1
2
3
4
5
9. Only a few people in my community look down on a Veteran.
1
2
3
4
5
10.Only a few people in my community think that Veterans are just as
intelligent as the average person.
1
2
3
4
5
11. Most employers in my community will hire a Veteran.
1
2
3
4
5
Agree
3
Section B. Community Perceptions
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
2
3
4
5
1
2
3
4
5
14. Only a few people in my community believe that a person with mental
illness is dangerous.
1
2
3
4
5
15. Most people in my community think less of a person with mental
illness.
1
2
3
4
5
16. Only a few people in my community look down on a person with mental
illness.
1
2
3
4
5
17. Only a few people in my community think that persons with mental
illness are just as intelligent as the average person.
1
2
3
4
5
18. Most employers in my community will hire a person with
mental illness.
1
2
3
4
5
Please indicate your agreement with each of the following statements
about your community.
Strongly
Agree
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
19. Most people in my community think that a person who has
attempted suicide can be trusted.
1
2
3
4
5
20. Most people in my community would not marry a person who has
attempted suicide.
1
2
3
4
5
21. Only a few people in my community believe that a person who has
attempted suicide is dangerous.
1
2
3
4
5
22. Most people people in my community think less of a person
who has attempted suicide.
1
2
3
4
5
23. Only a few people in my community look down on a person who has
attempted suicide.
1
2
3
4
5
24. Only a few people in my community think that persons who have
attempted suicide are just as intelligent as the average person.
1
2
3
4
5
25. Most employers in my community will hire a person who has
attempted suicide.
1
2
3
4
5
Please indicate your agreement with each of the following statements
about your community.
Strongly
Agree
12. Most people in my community believe that a person with mental
illness can be trusted.
1
13. Most people in my community would not marry a person with mental
illness.
Agree
Agree
4
Section C. Healthcare Utilization
The next set of questions asks about perceptions of suicide. We are interested in how likely the scenarios below are.
Please indicate the likelihood of each of the following statements.
Very
Likely
Likely
Neither
Likely nor
Unlikely
Unlikely
Very
Unlikely
26. If you were experiencing suicidal thoughts, how likely is it that you
would seek help from a primary care provider (e.g., physician, nurse)?
1
2
3
4
5
27. If you were experiencing suicidal thoughts, how likely is it that you
would seek help from a mental health professional (e.g.,
psychologist, social worker, counselor, psychiatrist)?
1
2
3
4
5
28. If you were experiencing suicidal thoughts, how likely is it that you
would seek help from friends?
1
2
3
4
5
29. If you were experiencing suicidal thoughts, how likely is it that you
would seek help from family?
1
2
3
4
5
30. If you were experiencing suicidal thoughts, how likely is it that you
would seek help from the faith-based community (e.g., clergy)?
1
2
3
4
5
31. If you were experiencing suicidal thoughts, how likely is it that you
would seek help from complementary and alternative medicine
practitioners (e.g., acupressure, acupuncture, yoga, energy healers)?
1
2
3
4
5
32. If you were experiencing suicidal thoughts, how likely is it that you
would seek help from a suicide hotline such as the 988 Suicide and
Crisis Lifeline (formerly the National Suicide Prevention Lifeline) or
the Veterans Crisis Line?
1
2
3
4
5
33. If someone you knew were experiencing suicidal thoughts, how
likely would you be able to talk to them about seeking help for their
suicidal thoughts?
1
2
3
4
5
34. If someone you knew were experiencing suicidal thoughts, how
likely would you be able to talk to them about safe storage of their
guns, such as storing them locked and unloaded?
1
2
3
4
5
35. In the past 12 months, have you suggested to anyone that they seek help, such
as from psychotherapy or counseling, for a mental health, psychological, or
emotional problem?
1
Yes
2
No
5
Section D. Media Awareness
36.Do you recently recall seeing, reading, or hearing about the Reach Out to Me campaign on TV, the radio, Internet, or
some other media source?
1
Yes
2
No
37.If presented with a friend or family member who is in a suicidal crisis, would you know where to get assistance?
1
Yes
2
No
Section E. Your Health
Now we will ask some questions about your current health.
38. In general, how would you rate your physical
health?
1
Excellent 2
Very Good 3
Good
4
Fair
5
Poor
39. In general, how would you rate your mental health,
including your mood and your ability to think?
1
Excellent 2
Very Good 3
Good
4
Fair
5
Poor
Section F. Exposure to Suicide
The next few questions concern your own experience with persons who have committed suicide. These questions could be
upsetting to some people.
40. Have you heard of anyone who has died by suicide in your community?
'Community' means different things to different people, so use the definition that makes the most
sense to you. In general, the area that you live in and the people you encounter there on a regular
basis.
41. Have you ever known anyone who died by suicide?
(If Yes, go to 41a -- If No, go to 42)
41a. (If Yes to 41) Was anyone you knew who died by suicide a family member?
1
Yes
1
Yes
2
No
1
Yes
2
No
2
No
3
Not
Sure
5
Not Close at All
41b. (If Yes to 41) What was your closest relationship to anyone you knew who died by suicide?
1
Very Close
2
Close
3
4
Moderately Close
Not Very Close
41c. (If Yes to 41) For the person you were closest to who died by suicide, how much of an effect did this person’s
suicide have on your life?
1
It had a devastating 2
effect on me that I
still feel
It had a devastating
effect on me but I no
longer feel that way
3
It disrupted
my life for a
short time
4
It had somewhat of an
effect on me, but did not
disrupt my life
5
It had little effect on
my life
6
Section G. Household Safety
42. Do you have access to firearms in your home?
1
Yes
2
No (If Yes, go to 43, If No, go to 45)
43. To what extent are the firearm(s) in your home stored
in a gun safe, locked cabinet, gun rack, or stored with a
trigger lock?
1
Not
Very
Often
2
Sometimes
3
Often 4
Very
Often
44. To what extent are the firearm(s) in your home stored
in an unloaded state?
1
Not
Very
Often
2
Sometimes
3
Often 4
Very
Often
45. Are there prescribed or unprescribed medications or
drugs in your home that could be life-threatening to
ingest?
1
Yes
2
No
46. To what extent are the medication(s) in your home
stored in a locked cabinet or storage device?
1
Not
Very
Often
2
Sometimes
47. Have any of your health care providers ever talked with
you about your firearms or access to firearms?
1
Yes
2
No
3
Not sure
48. Have any of your health care providers ever talked with
you about safe storage of medications or removing
excess medications from your home?
1
Yes
2
No
3
Not sure
(If Yes, go to 46,
If No, go to 47)
Not sure
3
3
Very
Often
Often 4
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
2
3
4
5
1
2
3
4
5
51. Temporary removal of firearms from the home, such as legal offsite
storage, can reduce the risk of dying by suicide.
1
2
3
4
5
52. Having excess or leftover medications in the home increases the risk of
dying by suicide.
1
2
3
4
5
53. Locking or securely storing excess or leftover medications in the home
can reduce the risk of dying by suicide.
1
2
3
4
5
54. Removing excess or leftover medications from the home can reduce
the risk of dying by suicide.
1
2
3
4
5
Please indicate your agreement with each of the following statements
about your community
Strongly
Agree
49. Having a firearm in the home increases the risk of dying by suicide.
1
50. Keeping firearms locked and unloaded can reduce the risk of dying by
suicide.
Agree
Section H. Community Environment
'Community' means different things to different people, so use the definition that makes the most sense to you. In general,
community is the area that you live in and the people you encounter there on a regular basis.
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
2
3
4
5
1
2
3
4
5
57. People in this community do not share the same values.
1
2
3
4
5
58. People in this community can be trusted.
1
2
3
4
5
59. People in this community generally don't get along with each other.
1
2
3
4
5
Please indicate how much you agree with each of the following:
Strongly
Agree
55. This is a close-knit community.
1
56. People in this community are willing to help each other.
Agree
7
Thank you for participating in the Community Opinion Survey. Your answers will help
improve existing suicide prevention efforts and create new programs to help both
Veterans, as well as all other people in the community at risk for suicide.
Please return this questionnaire in the enclosed postage-paid envelope. If the envelope is
missing, please mail the questionnaire to: Minuteman Technology Services | Survey
Processing Center | Post Office Box 540496 | Waltham, MA 02454-0496
Resources
Below are some resources that you may find helpful. If you have any questions, you can contact the research team by
phone 1-888-913-1380, email [email protected], or view the study information website at
communityopinionsurvey.org
Veterans who are in crisis or having thoughts of suicide, and those who know a Veteran in crisis, should contact the
Veterans Crisis Line (see the contact information below) for confidential crisis intervention and support available 24 hours
a day, 7 days a week, 365 days a year.
Suicide & Crisis Lifeline
988
Drug & Alcohol Treatment Hotline
1-800-662-4357
Help Finding a Therapist
1-800-843-7274
National Alliance on Mental Illness (NAMI)
1-800-950-6264
Veterans Crisis Line*
988 (Press 1)
*Send a text message to 838255 to connect with a VA responder or start
a confidential online chat session at VeteransCrisisLine.net/Chat
| File Type | application/pdf |
| File Modified | 2025-05-13 |
| File Created | 2025-05-09 |