10-317a SSG Fox SPGP - Eligibility Screening Form

OMB Control Number: 2900-XXXX

Estimated burden: 30 minutes

Expiration Date: 04/30/2025

Department of Veterans Affairs

Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP) 

Eligibility Screening Form

Paperwork Reduction Act and Privacy Statement: This information is being collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended to complete this eligibility screening will average 30 minutes. This includes the time needed to follow instructions, gather the necessary facts, and respond to the questions. This information is being collected to help inform eligibility for services under the SSG Fox SPGP by providing additional background information about the participants to better serve them. Any information provided will be kept private to the extent provided by law. Participation in this program is voluntary, and failure to respond will not have any impact on a participant’s entitlement to benefits.

Purpose

The SSG Fox Eligibility Screening form must be used by eligible entities that participate in the SSG Fox Suicide Prevention Program for a one-time capture to determine eligibility. Grantees will need to first review Veteran status and potential risk for suicide. This form will assess the presence of potential suicide risk factors. For the purposes of this program, risk of suicide means exposure to, or the existence of, any of the following factors as defined by 201(q)(8)(A).

Instructions

The form must be completed for each potential individual screened by the grantee. If one or more suicide risk factors are present, grantees will then administer a suicide risk screening to complete the process and attain an eligibility determination. Additional information for using the form will be available upon eligible entity award.

Date:_______________________________

Agency or Provider ID Code: __________

First: ___________________Middle:________________ Last Name:__________________________

Eligibility Status

An eligible individual must one of the following:

(A) a veteran as defined in section 101 of title 38, United States Code; 38 U.S. Code § 101,or

(B) an individual described in section 1720I(b) of such title 38 USC 1720I; or

(C) an individual described in any of clauses (i) through (iv) of section 1712A(a)(1)(C) 38 U.S.C. 1712A of such title

Is the person confirmed to be an eligible individual?

☐ YES ☐ NO

If Yes, continue to next section. If No, refer out to community resources.

Suicide Risk Factors

Impacts on individual's mental health and wellbeing within the last 30 days?

(Mark yes or no for all that apply)

1. Health risk factors

   1. mental health challenges ☐ YES ☐ NO

   2. substance use challenges ☐ YES ☐ NO

   3. serious or chronic health conditions or pain ☐ YES ☐ NO

   4. traumatic brain injury ☐ YES ☐ NO

2. Environmental risk factors

   1. prolonged stress ☐ YES ☐ NO

   2. stressful life events ☐ YES ☐ NO

   3. unemployment ☐ YES ☐ NO

   4. homelessness ☐ YES ☐ NO

   5. recent loss ☐ YES ☐ NO

   6. legal or financial challenges ☐ YES ☐ NO

3. Historical risk factors,

   1. previous suicide attempts ☐ YES ☐ NO

   2. family history of suicide ☐ YES ☐ NO

   3. history of abuse, neglect or trauma ☐ YES ☐ NO

TOTAL: __/13

Veteran has endorsed at least 1 YES on the list of the risk factors. ☐YES ☐ NO

If yes, please proceed to the suicide risk screening, Columbia-Suicide Severity Rating Scale (C-SSRS) to complete the process and attain an eligibility determination.

If No, refer out to community resources.

VA Form 10-317a 11MHSP