Training Utilizati Training Utilization and Preservation Baseline

OMB No. 0930-NEW

Expiration Date: XX/XX/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 0930-XXXX. 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 or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E45,Rockville, Maryland, 20857.

Zero Suicide Evaluation

Training Utilization and Preservation Survey (TUP-S) Baseline

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 15 minutes to complete.

A sample of participants who complete today’s survey will be eligible to participate in two follow-up surveys. If you are selected to participate in these additional follow-up surveys, you will receive $10 per follow-up survey. There will be more information at the end of the survey about these data collection efforts.

 

Right 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.  

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.   

 

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.

Please click the "PROCEED” button below to proceed.

• PROCEED

Section 1. Skills Assessment

These questions ask about your knowledge and skills related to suicide prevention.

1. Please rate how confident you are about your knowledge on:

	Very Confident	Confident	Somewhat confident	Not at all confident
Suicide prevention and treatment
Accessing useful resources for suicide prevention
Culturally adapted approaches to suicide prevention
Purpose of your role in suicide prevention
Educating your community about suicide prevention
Skills required to prevent suicide or reduce the problems that might lead to suicide (e.g., depression, substance use)

2. Please rate your knowledge on:

	Very High	High	Low	Very Low
Policies and procedures that define each employee’s role in preventing suicide
Warning signs of suicide
How to ask someone about suicidality
Persuading someone to get help
Risk factors for suicide

 

3. Please rate your ability to: 

	Very Confident	Confident	Somewhat confident	Not at all confident
Recognize suicidality (including warning signs)
Conduct a suicide risk assessment
Engage and connect with a person who is suicidal
Identify appropriate response to a person in crisis
Make appropriate referrals and connections
Counsel on access to lethal means
Help someone create a collaborative safety plan

 

Section 2. Plans After Training

6. How do you intend to use what you learned during this training? Select all that apply.

• Screen individuals for suicidal behaviors (i.e., using a screening tool)

• Formally publicize information about suicide prevention and mental health resources

• Have informal conversations about suicide and suicide prevention with other individuals

• Identify individuals who might be at risk for suicide

• Provide direct services to individuals at risk for suicide

• Provide direct services to the families of individual at risk for suicide Train other staff members

• Make referrals to mental health services for individuals at risk

• Work with additional at-risk populations

• Other, please describe: _______________________________

• I don’t know how I will use this training

7. What areas related to suicide prevention would you like to learn more about, receive additional training on, or access 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

Section 3. Work Background

8. Please choose the one category below that best describes your primary professional role. Please select one.

• 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)

• Other, please specify: ______________________________

Section 4. About Yourself

9. How old are you?

_______years 

• I prefer not to answer 

10. What is your race and/or ethnicity? Select all that apply and enter additional details in the spaces below.

• American Indian or Alaska Native - Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

[PROGRAMMER: This is an open-text response option]

• Asian – Provide details below.

• Chinese

• Vietnamese

• Asian Indian

• Korean

• Filipino

• Japanese

• Enter, for example, Pakistani, Hmong, Afghan, etc.

[PROGRAMMER: This is an open-text response option]

• Black or African American – Provide details below.

• African American

• Nigerian

• Jamaican

• Ethiopian

• Haitian

• Somali

• Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc. [PROGRAMMER: This is an open-text response option]

• Hispanic or Latino – Provide details below.

• Mexican

• Cuban

• Puerto Rican

• Dominican

• Salvadoran

• Guatemalan

• Enter, for example, Colombian, Honduran, Spaniard, etc.

[PROGRAMMER: This is an open-text response option]

• Middle Eastern or North African – Provide details below.

• Lebanese

• Syrian

• Iranian

• Iraqi

• Egyptian

• Israeli

• Enter, for example, Moroccan, Yemeni, Kurdish, etc.

[PROGRAMMER: This is an open-text response option]

• Native Hawaiian or Pacific Islander – Provide details below.

• Native Hawaiian

• Tongan

• Samoan

• Fijian

• Chamorro

• Marshallese

• Enter, for example Chuukese, Palauan, Tahitian, etc.

[PROGRAMMER: This is an open-text response option]

• White – Provide details below.

• English

• Italian

• German

• Polish

• Irish

• Scottish

• Enter, for example, French, Swedish, Norwegian, etc.

[PROGRAMMER: This is an open-text response option]

• I prefer not to answer 

11. What do you consider yourself to be? Please select one.

• Male 

• Female 

• Transgender (Male to Female) 

• Transgender (Female to Male) 

• Gender non-conforming 

• Two Spirit [RESPONSE ONLY AVAILABLE TO THOSE THAT INDICIATE AI/AN in Q10] 

• I use a different term, please specify: ________________ 

• I prefer not to answer 

12. Are you a Veteran? Please select one.

• Yes

• No

• I prefer not to answer

13. What is the highest degree or level of school that you completed? Please select one.

• Less than high school

• High School with diploma or GED/Alternative credential

• Trade/technical/vocational training

• Some College

• Associate Degree

• Bachelor’s Degree

• Masters degree

• Doctorate degree (PhD)

• Medical Degree (MD)

• Other (please specify):

14. How many years of work experience do you have related to suicide prevention?

[Drop down of numbers]

Section 5. Consent to Contact

Thank you for completing this survey! A sample of participants who completed today’s survey will be eligible to participate in up to two additional follow-up surveys to help us better understand how this training has impacted your confidence levels, knowledge, practices, and utilization of Zero Suicide skills over time. If you are selected for participation, a member of the team will invite you to complete the follow-up survey in 6 and 12 months after today’s date. You will receive a $10 electronic gift card per completed survey. If you are interested and selected for participation, we will reach out through the contact information that you provided below to share additional details about participation.

15. Are you interested in participating in the follow-up surveys in 6 and 12 months from today?

• Yes

• No

16. [IF YES], please provide the following information:

Name:

Best contact number to reach you:

Your work email:

Your personal email:

I don’t have a personal email (include a checkbox)

Best Email to reach you:

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Zero Suicide Evaluation Training and Utilization Preservation Survey Baseline – DRAFT

06.18.24