Training Activity Training Activity Summary Page

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 Activity Summary Page (TASP)

Directions: The following information should be completed by the program staff or training facilitator. This form should be completed for every training activity implemented as part of the Zero Suicide program.

Section 1. Training Information

1. Name of training
2. Training identification (site ID + 3 digits)
3. Name of the Organization that hosted this training
4. Please select the format of this training				In-Person [continue to 4a] Virtual facilitated Both In-Person and Virtual Components [continue to 4a] Virtual Self-directed/self-paced
	4a. [If In-Person or Both In-Person and Virtual], please provide the name of the facility where the training took place.
5. Date of the training. Enter date offered, date range, or select ‘No specific end date’ if the training is available on an on-going basis.				Single date: MM/DD/YYYY Date Range: MM/DD/YYYY to MM/DD/YYYY No specific end date
6. Type of training curricula implemented: Please select one.
Acceptance and Commitment Therapy (ACT) Applied Suicide Intervention Skills Training (ASIST)   Ask Suicide Screening Questions (asQ)  Assessing and Managing Suicide Risk (AMSR)  Attachment-Based Family Therapy (ABFT) Attempted Suicide Short Intervention Program  Beck Depression Inventory (BDI)  Behavioral Health Measure-10 (BHM-10)  Behavioral Health Screen (BHS)  Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT) Brief Mindfulness-Based Intervention for Suicidal Ideation  Brief Symptom Inventory 18 (BSI 18)  CALM (Counseling on Access to Lethal Means)  Chronological Assessment of Suicide Events (CASE)   Cognitive Therapy – Suicide Prevention (CT-SP) Collaborative Assessment and Management of Suicidality (CAMS)  Columbia Suicide Severity Rating Scale (CSSR-S)  Connect Postvention Training  Connect Suicide Prevention/Intervention Training  Dialectical Behavior Therapy (DBT)				Outcome Questionnaire 45.2 (OQ 45.2)  Patient Health Questionnaire 9 (PHQ-9)   PHQ-3  Preventing Suicide in Emergency Department Patients QPR-T (suicide risk assessment and training course)   Question, Persuade, Refer (QPR): Gatekeeper Training for Suicide Prevention  Recognizing & Responding to Suicide Risk in Primary Care Recognizing and Responding to Suicide Risk (RRSR)  SafeSide Behavioral Health SafeSide Primary Care  SafeSide Youth Services Safety Planning for Youth Suicide Prevention  Suicide Alertness for Everyone: Tell, Ask, Listen, and Keep Safe (safeTALK)  Suicide Behaviors Questionnaire (SBQ-R)  Suicide in the Military (Psych/Armor) Teachable Moment Brief Intervention Locally developed training, please specify: ­­­­­­­­­­­­­­­­­­­­­_________________________________ Other Training (Go to 6a and 6b)
		6a. If you have selected “Other,” please specify type of training curricula implemented (not name of training)
		6b. If you have selected “Other” as type of training, please select one of the following:		Risk Assessment training Screener training Clinical intervention/Treatment training Postvention training
7. Duration of the training				Hours Minutes
8. What is the primary intended outcome for participants in this training? Please select one.		Screen patients for suicide risk (using a screening tool) Assess patients level of suicide risk Identify patients who might be at risk for suicide Provide direct services to patients at risk for suicide Train other staff or community members Make referrals to mental health services for at-risk patients Other, please specify: ______________________
9. Is this a train-the-trainer event?				Yes No
10. Is this a booster or follow-up training?				Yes [Go to 11] No [Complete 10a]
		10a. If no, are there any plans to conduct follow-up or booster trainings in the future?		Yes No Don’t know
11. Will/was behavioral rehearsal or role-play included as a part of the training?				Yes [Go to 11a] No [Complete 12]
		11a. [IF YES], Will/did the training participants engage in the behavioral rehearsal or role-play during the training event?		Yes [Go to 11b, c, and d] No [Complete 12]
		11b. [IF YES], how many role-play practices will be/were conducted during the training event?		1 2 3 4 or more
		11c. [IF YES], How many total minutes will be/were spent on role play practices during the training event?		Less than 5 5 10 15 20		25 30 35 or more
		11d. Will/was behavioral rehearsal or role-play given as homework exercises after the training?		Yes No
12. What resources or materials will be/were provided to trainees? Select all that apply.			Local crisis center information Mobile or online tools or applications for suicide prevention [complete 12a-b] Fact/resource sheets Wallet card information No resources or materials were provided to trainees at the training event
		12a–b. If mobile or online tools or applications for suicide prevention will be/were provided, please provide the name and description of the tool(s).			Name: Description:
13. Were there any challenges with implementing this first training?					Yes [Go to 13a,b] No [Go to 14]
13a. [IF YES], can you describe these challenges?					Open Ended Response
13b. [IF YES], What do you think would best address these challenges?					Open Ended Response

Section 2. Trainee Information

14. Total number of trainees who attended the training:
15. Number of trainees with a primary role in each category (participants should only be counted in one category):
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)
Don’t know
Other [complete 15a]
15a. If other, please specify:

Section 3. Government Performance and Results Act (GPRA) Information

The following information on the number of trainees in the Workforce Development 2 (WD2) category is required for posting GPRA data to the Suicide Prevention Data Center. For further details about reporting GPRA information to SAMHSA, please contact your SAMHSA Government Project Officer (GPO). The WD2 category is defined as the number of people in the mental health and related workforce trained in mental health-related practices/activities that are consistent with the goals of the grant. Note: Do not leave this question blank. If none of the trainees belong to this category, enter 0.

16. Total WD2:

This is the end of the survey.

Thank you for taking the time to complete this survey. Your participation is critical to the success of the Zero Suicide Evaluation.

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Zero Suicide Evaluation Training Activity Summary Page – DRAFT

03.06.24