OMB No: XXXXX
Expiration Date: XXXX
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 XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 30 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, 5600 Fishers Lane, Room 15E57B, Rockville, MD 20857.
Zero Suicide Evaluation
6/12 Month Follow Up Training Utilization and Preservation Survey (TUP-S)
Description of Participation Thank you so much for taking the time to speak with me today. My name is [NAME] and I work for Aptive/ ICF. The Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services is evaluating their Zero Suicide in Health Systems program. Aptive Resources along with its partner ICF (together as Team Aptive) are contracted by SAMHSA to conduct this evaluation. We are asking you to complete this that survey that will assess your knowledge, attitudes, and behaviors related to suicide prevention at the initial training. The survey will take approximately 30 minutes to complete.
Rights Regarding Participation
Your participation in this survey is completely voluntary.
There are no penalties or consequences to you if you do not participate.
You may stop the survey or skip a question at any time for any reason.
You may contact the evaluation principal investigator with any questions you have before, during, or after completion.
The survey must be completed to receive compensation.
Privacy
We will take every precaution to protect your privacy.
All survey responses will be confidential. Your name will never appear in any report. All findings will be reported in aggregate; that is, they will be combined with responses from other individuals. If you are selected to participate in follow-up surveys your responses across administration will be linked with a unique identifier, but —your name and responses will not be linked. Your individual responses will not be shared with anyone, including your employer or other grantee-funded staff.
Contact information will be entered into a password-protected database which can only be accessed by a limited number of individuals (selected Team Aptive staff) who require access.
Benefits
Your participation will not result in any direct benefits to you. However, your input will contribute to a national effort to prevent suicide.
Risks
Completing
this survey poses few, if any, risks to you. Some questions may make
you feel uncomfortable. You can choose not to answer any question
for any reason. You may choose to stop the survey at any time, or
not answer a question for whatever reason. You will not be penalized
for stopping. You can contact the principal investigator of the
project at any time.
Incentive
You will receive a $10 gift card for your completion of today’s survey.
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 (646) 695-8154 or christine.walrath@icf.com.
For any questions related to your rights as they related to this research, please contact the ICF IRF at IRB@icf.com.
PROCEED
Training Verification
Please verify that you attended the following training: [auto populated with name and date of training ]
Yes, this is the training I attended.
No, this is not the training I attended [END SURVEY]
Section 1. Training Utilization within Healthcare Settings
For these questions in this section, please think about the [name of training] that you took on [date of training].
1. Have you used your training to do any of the following?
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Yes |
No |
Not Applicable |
Don’t know |
a. Screen patients for suicidal behaviors (i.e., using a screening tool) |
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b. Formally publicize information about suicide prevention or mental health resources at your healthcare organization |
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c. Have informal conversations about suicide and suicide prevention with patients |
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d. Have informal conversations about suicide and suicide prevention with other staff members |
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e. Identify patients who might be at risk for suicide |
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f. Provide direct services to patients at risk for suicide |
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g. Provide direct services to the families of patients at risk for suicide |
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h. Train other staff members to intervene with patients at risk for suicide |
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i. Make referrals to mental health services for at-risk patients |
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2. Have you used the suicide prevention training to do anything not previously mentioned?
Yes [Continue to 2a]
No [Continue to 3]
2a. Please describe what you did. [Note to Survey Developer: Limit characters to 2,000]
3. In the last 6months, how many trainings or presentations about suicide or suicide prevention have you attended? [Please do not include booster or refreshers of the training during which you consented to participate in this survey.]
None [Skip to 4]
1 [Continue to 3a]
2-5 [Continue to 3a]
6-10 [Continue to 3a]
10+ [Continue to 3a]
3a. Which training(s) about suicide or suicide prevention have you received? Select all that apply.
[Display each type of training (the trainings in BOLD) per screen along with the question 3a].
Training for All Individuals
Assessing and Managing Suicide Risk (AMSR)
Applied Suicide Intervention Skills Training (ASIST)
Connect Suicide Prevention/Intervention Training
Connect Postvention Training
Question, Persuade, Refer (QPR): Gatekeeper Training for Suicide Prevention
Suicide Alertness for Everyone: Tell, Ask, Listen, and Keep Safe (safeTALK)
Training on Screening Practices
Patient Health Questionnaire 9 (PHQ-9)
PHQ-3
Columbia Suicide Severity Rating Scale (CSSR-S)
Behavioral Health Screen (BHS)
Ask Suicide Screening Questions (asQ)
Beck Depression Inventory (BDI)
Suicidal Behaviors Questionnaire (SBQ-R)
Behavioral Health Measure-10 (BHM-10)
Brief Symptom Inventory 18 (BSI 18)
Outcome Questionnaire 45.2 (OQ 45.2)
Trainings for Clinical Assessment and Management of Suicide Risk
Assessing and Managing Suicide Risk (AMSR)
Chronological Assessment of Suicide Events (CASE)
Collaborative Assessment and Management of Suicidality (CAMS)
Recognizing and Responding to Suicide Risk (RRSR)
QPR-T (suicide risk assessment and training course)
Clinical Trainings for the Treatment of Suicidal Ideation and Behaviors
Attachment-Based Family Therapy (ABFT)
Cognitive Therapy – Suicide Prevention (CT-SP)
Collaborative Assessment and Management of Suicidality (CAMS)
Dialectical Behavior Therapy (DBT)
Teachable Moment Brief Intervention
Attempted Suicide Short Intervention Program
Brief Mindfulness-Based Intervention for Suicidal Ideation
Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT)
Acceptance and Commitment Therapy (ACT)
Training in Safety Planning and Lethal Means Safety Practices
CALM (Counseling on Access to Lethal Means)
Safety Planning for Youth Suicide Prevention
Trainings for All Clinical Staff (Specific Settings or Populations)
Suicide in the Military (Psych/Armor)
SafeSide Behavioral Health
SafeSide Youth Services
Trainings Specific to Emergency Department and Primary Care Settings
Preventing Suicide in Emergency Department Patients
Recognizing & Responding to Suicide Risk in Primary Care
SafeSide Primary Care
Not Sure
4. In the last 6 months, have you received any booster or refresher sessions directly related to the training?
Yes
No
Not Sure
5. In the last 6 months, have you used any online tools or applications (apps) to support what you learned from the training?
Yes [Continue to 5a]
No [Skip to 5b]
Don’t know [Skip to 6]
5a. [If yes in 5], what tools or apps have you used? [Note to Survey Developer: Limit characters to 2,000]
5b. [If no in 5], can you describe why? [Note to Survey Developer: Limit characters to 2,000]
6. In the last 6 months, have you experienced any challenges with participating in additional training sessions such as booster or refresher trainings?
Yes [Continue to 6a]
No [Skip to 7]
Don’t know
6a. [If yes in 6], can you describe these challenges? [Note to Survey Developer: Limit characters to 2,000]
7. In the last 6 months, have you shared information from the training with any others at your healthcare organization?
Yes
No
8. In the last 6 months, have you shared information from the training with anyone outside of your healthcare organization? This may include your friends and/or family.
Yes [Continue to 8a]
No [Skip to 9]
8a. [If yes in 8], How did you share the information? Select all that apply.
Shared printed materials
Shared information verbally
Shared information via training or presentation
Don’t know
Section 2. Impact of Zero Suicide Training
Please read the following statements and use the rating scale to indicate how much you agree or disagree with each statement. This section pertains to the [name of training] that you took on [date of training]. It is important that you answer all statements according to your beliefs and not what you think others may want you to believe.
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Strongly Agree |
Agree |
Neutral |
Disagree
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Strongly Disagree |
9. The training increased my knowledge about suicide prevention |
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10. The training resources I received (e.g., brochures, wallet cards) have been very useful for my suicide prevention efforts |
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11. The training promotes understanding about cultural differences in the community that I serve |
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12. The training has proven practical to my work and/or my daily life |
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Section 3. Knowledge about Suicide Prevention
Please read the following statements and use the rating scale to indicate your knowledge of the following items.
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Very High |
High |
Low |
Very Low
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N/A or No Opinion |
13. My organization’s policies and procedures that define each employee’s role in preventing suicide |
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14. Warning signs of suicide |
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15. How to ask someone about suicidality |
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16. Persuading someone to get help |
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17. Risk factors for suicide |
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18. Local referral services |
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19. Treatment and therapies |
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Section 4. Confidence in Identifying and Managing Suicidal Thoughts and Behaviors
Please read the following statements and use the rating scale to indicate how much you agree or disagree with each statement. Think about the [name of training] that you took on [date of training] when you are answering these statements. It is important that you answer all statements according to your beliefs and not what you think others may want you to believe.
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Strongly Agree |
Agree |
Neutral |
Disagree |
Strongly Disagree |
20. If someone I knew was showing signs of suicide, I would directly raise the question of suicide with them |
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21. If a person’s words and/or behavior suggest the possibility of suicide, I would ask the person directly if he/she is thinking about suicide |
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22. If someone told me they were thinking of suicide, I would intervene |
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23. I don’t think I can prevent someone from suicide |
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24. I don’t feel competent to help a person at risk of suicide |
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25. How confident do you feel in your ability to….
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Very Confident |
Confident |
Somewhat Confident |
Not at all Confident |
N/A or No Opinion |
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Section 5. Social Connections Related to Suicide Prevention
Please read the following statements and use the rating scale to indicate how much you agree or disagree the degree to which you agree or disagree with each statement. Think about the [name of training] that you took on [date of training] when you are answering these statements. It is important that you answer all statements according to your beliefs and not what you think others may want you to believe.
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Strongly Agree |
Agree |
Disagree |
Strongly Disagree
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N/A or No Opinion |
26. Since the training, I have developed stronger relationships which helped me feel confident in suicide prevention skills and knowledge. |
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27. The training has helped me feel confident in connecting with different individuals in my healthcare organization to address suicide prevention. |
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28. The training has increased my awareness about the importance of communication and its role in suicide prevention at my workplace. |
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29. As a result of the training, I have a greater sense of competence to address suicide prevention at my workplace. |
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Section 6. Skills and Experience with Individuals at Risk for Suicide
The next set of questions asks about your experiences with individuals at risk for suicide since when you participated in [name of training] on [date of training].
[Only individuals who answer Yes to Q1E or Q1F will answer questions in this section]
30. [If Yes to Q1E or Q1F] ,You selected that in the last 6 months you used your suicide prevention training to identify individuals you thought might be at risk for suicide. About how many individuals have you identified in the last 6 months?
1-2
3-5
6-10
11+
I did not identify any individuals in the last 6 months [Skip to 46]
31. Thinking about all the individuals you identified, about how many did you refer for further assistance or support?
1-2
3-5
6-10
11+
32. Thinking about the one individual you identified most recently, did you ask the individual whether they were considering suicide?
Yes
No
Don’t know
33. Thinking about the one individual you identified most recently, in what setting were they identified?
Pediatric clinic
Primary care clinic
General Hospital
Private behavioral health clinic
Psychiatric hospital
Behavioral health outpatient clinic
Emergency Response Unit or Emergency Department
Other, please specify:_____________
34. Thinking about the one individual you identified most recently, did you connect the individual you identified to get further assistance or support?
Yes [Continue to 34a and 34b]
No [Skip to 35]
Don’t know [Skip to 35]
34a. To what extent were you able to connect the individual that you identified to these services, resources, or individuals for further assistance or support?
Internal (Within the healthcare organization where you work)
External (Outside of the healthcare organization where you work)
34b. Please briefly describe these identified services, resources, or individuals. [Note to Survey Developer: Limit characters to 2,000]
35. Thinking about the one individual you identified most recently, did you take the individual to any of the services or resources you were recommending?
Yes
No
Don’t know
36. Thinking about the individual you identified most recently, did you notify that referral resource about the referral?
Yes
No
Don’t know
37. Thinking about the one individual you identified most recently, did the individual receive the services to which they were referred?
Yes
No
Don’t know
38. Thinking about the individual you identified most recently, did you receive a formal confirmation that the individual received the service?
Yes
No
Don’t know
39 . Thinking about the one individual you identified most recently, have you personally followed up with them to see how they are doing?
Yes
No
Don’t know
40 . Thinking about the one individual you identified most recently, , about how many days did it take from the time you made the referral to when the individual received his or her first service?
Less than 1 day
Less than 1 week
Between 1 and 2 weeks
More than 2 weeks and up to 4 weeks
More than 1 month
Don’t know
41. Thinking about the one individual you identified most recently, what was the first service he or she received?
Mental health assessment
Substance use assessment
Mental health counseling
Substance abuse counseling
Inpatient or residential psychological services
Psychiatric services or medication management without therapy
Some other service not mentioned, please describe:__________________
Don’t know
42. Did he or she receive any additional behavioral health services since that first appointment?
Yes [Continue to 42a]
No [Skip to 43]
Don’t know [Skip to 43]
42a. [If Yes in 42], What additional mental health and/or substance use services did he or she receive?
Mental health assessment
Substance use assessment
Mental health counseling
Substance abuse counseling
Inpatient or residential psychological services
Psychiatric services or medication management without therapy
Some other service not mentioned, please describe:__________________
Don’t know
43. Thinking back to the most recent individual you identified who actually received services, how satisfied are you that your training prepared you to take actions that were appropriate and effective?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
Don’t know
44. Have you received recognition from your organization for your use of knowledge and skills learned at this training?
Yes
No
Don’t know
45. Have you received any training to support your ability to track or monitor individuals that you identified as at risk for suicide?
Yes
No
Don’t know
Section 8. Additional Training Questions
The next set of questions will ask about your current role at your work organization to help better understand the national profile of workers involved in suicide prevention.
46. Are you currently employed at the same organization where you initially took the training [PIPE]
Yes
No
Don’t know
47. Please indicate the primary setting in which you currently interact with individuals at risk for suicide.
Pediatric Clinic
Primary care clinic
General Hospital
Private behavioral health clinic
Psychiatric hospital
Behavioral health outpatient clinic
Emergency Response Unit or Emergency Department
Other, please describe:___________________
48. You previously indicated that the role that best describes you is [pipe from TUP-B/TUP-6]. Has your role changed?
Yes [Go to 48a]
No [Skip to 49]
Don’t know [Skip to 49]
48a. [If yes in 48], please select the ONE ROLE below that you feel best describes you.
Management (Administrators, Supervisors, Managers, Coordinators)
Business, Administrative, and Clerical (Accounting, Reception, Human Resources, Billing, Records, Information Technology)
Facility Operations (Dietary, Housekeeping, Maintenance, Security, Transportation)
Behavioral Health Clinician (Counselor, Social Worker, Substance Abuse Counselor, Therapist, Psychologist)
Adjunct Therapist (Activity, Occupational, Physical, Rehabilitation)
Case Management
Crisis Services
Physical Health Care/Medication Management (Physician, Nurse Practitioner, Physician’s Assistant)
Nursing (Nurse, Registered Nurse)
Psychiatry (Psychiatrist, Psychiatric Nurse Practitioner)
Technician (Mental Health Technician, Behavioral Technician, Patient Care Assistance, Residential Technician)
Patient Observer
Support and Outreach (Outreach, Faith, Family Support, Peer Support)
Education (Teacher, Health Educator)
49. In the last 6/12 months, have you used the skill you learned during this training in any setting other than your workplace?
Yes [Complete 49a]
No [Skip to 50]
Don’t know [Skip to 50]
49a. [if YES in 49] Please describe where and how you used the skills you learned from this training.
Section 9. Organizational Policies
The next set of questions will ask for some information about your current organization.
50. Thinking about the primary setting in which you interact with individuals, about how many other colleagues in that setting have received training in suicide prevention?
All
Most
Some
None
Don’t Know
51. To your knowledge, do new staff members from your organization receive this training?
Yes
No
Don’t know
52. Is there someone at your agency who serves as a champion for staff attending this training?
note: A champion is a person who supports suicide prevention training. Another name for champion is advocate, promoter, supporter.
Yes [Continue to 52a]
No [Skip to 53]
Don’t know [Skip to 53]
52a. [IF Yes in 52], how often do you interact with this person?
Daily
Once a week
Once a month
Rarely
Never
Don’t know
53. In the setting where you interact with individuals, is there an established, shared protocol regarding steps that should be followed after an individual is identified as at risk for suicide?
Yes
No
Don’t know
54. In the setting where you interact with individuals, are there clear, widely used steps that should be followed after a referral is made to make sure the individual received the services?
Yes
No
Don’t know
55. How important do you think this training is to the mission of your community or workplace?
Very important
Important
Neither important nor unimportant
Unimportant
Very unimportant
Don’t know
56. What are the facilitators to implementing suicide prevention activities in the setting in which you interact with individuals at risk for suicide? Note: A facilitator may be something that aids or makes it easier to implement suicide prevention activities. Select all that apply.
Training/professional development opportunities
Increased community awareness
Community resources
Community collaboration
State, tribe, or agency prioritization of suicide prevention
Something else, please describe:___________________
Don’t know
57. What are the barriers to implementing suicide prevention activities in the setting in which you interact with individuals at risk for suicide? Select all that apply.
Access to appropriate services
Lack of awareness about the problem of suicide
Time constraints
Workplace characteristics
Lack of funding
Something else, please describe:_______________________
Don’t know
58. Based on your experience after the training event that you attended 6 months ago, are there any additional areas that you are interested in learning to support your training in suicide prevention
Yes [Continue to 58a]
No [END SURVEY]
58a. [If yes in 58] What areas related to suicide prevention would you be interested in training, learning, or need more resources? Select all that apply.
General suicide prevention and awareness
Identification of risk factors and warning signs
Screening and Assessment practices
Treatment practices and approaches
Safety planning
Crisis communication
Transition of care practices
Staff roles and responsibility within your work environment
Policies and procedures within your work environment
Ethical and legal considerations
Epidemiology and latest research findings
This is the end of the survey. [IF Respondent is taking this survey at 6 month mark] Thank you for completing this survey. As a friendly reminder, we need your help in participating in this survey again at the 12-month mark after the date that you completed the [Prepopulate name of Zero Suicide training. Sincethis is your first time taking this survey, you will be invited to participate again in 6 months. We appreciate your time in taking this survey. Your participation is critical to the success of the Zero Suicide Evaluation. You will receive a $10 as an incentive for completing this survey.
[If respondent is taking this survey at the 12-month mark] Congratulations! You have completed both follow-up surveys. Since this is your 12-month survey, we will not contact you again to complete this survey. We appreciate your time in taking this survey. Your participation is critical to the success of the Zero Suicide Evaluation. You will receive a $10 as an incentive for completing this survey.
TUPS-ZS-Draft
12/03/2023
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