MSPN Community Coalition Registration Application Survey

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* 4. Does your coalition have a formally authorized lead organization

Not Sure

If Yes, what is the organizations name?

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* 5. Does your coalition have a fiscal agent?

Not sure

If Yes, what is the organization's name and address?

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* 6. Coalition mailing address, city, and zip code:

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* 7. Does your Coalition have a website or social media handles? Please list them.

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* 8. Upload Coalition Logo if applicable

Attach logo here. Only PDF, DOC, DOCX, PNG, JPG, JPEG, GIF files are supported.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 9. Coalition leader's name:

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* 10. Coalition leader's email:

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* 11. Coalition leader's phone number:

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* 12. Coalition leader's preferred method of contact:

Phone

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* 13. Alternate contact or additional Coalition leader's name:

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* 14. Alternate contact or additional Coalition leader's email:

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* 15. Does the coalition have a mission statement?

If yes, please state the mission:

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* 16. Approximate size of your Coalition:

10 or less members

11-25 members

26-50 members

Over 50 members

I don't know

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* 17. Please identify the sectors your Coalition members represent: (Check all that apply)

Suicide prevention organizations (e.g., American Foundation for Suicide Prevention)

Individuals with lived experience (e.g., suicide survivors and/or loved ones impacted by suicide)

Civic leaders

Locally elected officials

Faith community

Parents

Youth

K-12 Schools, employees, and/or administration

Colleges/universities

Law enforcement/criminal justice organizations

First responders

Coroners/medical examiners

Public health agencies (e.g., health departments)

Healthcare providers (including physical and mental health)

Substance use prevention providers

Social service providers (e.g., housing, food assistance, employment, education, domestic violence)

Media representatives

Local ethnic/racial representatives

Grassroots community organizations

Businesses

Other (please specify)

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* 18. Please list the Coalition's goals and objectives

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* 19. Briefly describe any activities/focus for your Coalition related to suicide prevention efforts:

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* 20. How long has the Coalition been in existence?

Less than a year

1-2 years

3-4 years

5 or more years

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* 21. How often does the Coalition meet

More than once a month

Monthly

Every other month

Quarterly

A few times a year

Annually

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* 22. How does your Coalition meet?

In-person

Virtually

Hybrid (virtual and in-person options)

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* 23. Describe the geographic area served by the Coalition by identifying the counties, cities, school districts, zip codes, census tracts, or block groups fully served.

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* 24. When was the last community needs assessment conducted that included suicide-specific information?

Past Year

Past 2 years

Over 2 years ago

Never

I don't know

Other (please specify)

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* 25. If a community needs assessment was conducted, did it include suicide-specific information or was suicide prevention identified as a community priority or need?

N/A

I don't know

Yes, please explain:

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* 26. Are suicide prevention activities a part of the Coalition's comprehensive prevention plan?

I don't know

If Yes, please explain:

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* 27. Does the Coalition support or implement any evidence-based programs or best practices relating to suicide prevention?

I don't know

If Yes, please explain

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* 28. What types of activities does your Coalition plan and support relating to suicide prevention?

Policy/advocacy

Awareness messaging and/or media campaigns

Community education/outreach

Capacity building, training, and/or technical assistance

Strategic planning

Coalition building

Lethal means safety and resources (e.g., trigger/cable locks, medication lock boxes, etc.)

Conferences and/or meetings open to a wider audience

Other (please specify)

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* 29. Does your Coalition have any paid staff?

If Yes, please explain:

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* 30. Please list the Coalition’s current funding sources:

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* 31. Indicate below if you would like to opt in to any of the below email lists or to receive follow-up information (select all that apply).

MSPN

Suicide Prevention Academy

What is the email address for receiving these newsletters and updates?

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* 32. Please check the box below if you consent to your Coalition information being shared.

I am aware that the information provided may be posted on the Missouri Suicide Prevention Network website and viewed by the general public:

MSPN Community Coalition Registration Application

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* 1. What type of application is this? Check one.

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* 2. Date of application:

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* 3. What is your Coalition's name?

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* 4. Does your coalition have a formally authorized lead organization

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* 5. Does your coalition have a fiscal agent?

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* 6. Coalition mailing address, city, and zip code:

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* 7. Does your Coalition have a website or social media handles? Please list them.

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* 8. Upload Coalition Logo if applicable

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* 9. Coalition leader's name:

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* 10. Coalition leader's email:

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* 11. Coalition leader's phone number:

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* 12. Coalition leader's preferred method of contact:

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* 13. Alternate contact or additional Coalition leader's name:

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* 14. Alternate contact or additional Coalition leader's email:

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* 15. Does the coalition have a mission statement?

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* 16. Approximate size of your Coalition:

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* 17. Please identify the sectors your Coalition members represent: (Check all that apply)

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* 18. Please list the Coalition's goals and objectives

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* 19. Briefly describe any activities/focus for your Coalition related to suicide prevention efforts:

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* 20. How long has the Coalition been in existence?

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* 21. How often does the Coalition meet

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* 22. How does your Coalition meet?

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* 23. Describe the geographic area served by the Coalition by identifying the counties, cities, school districts, zip codes, census tracts, or block groups fully served.

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* 24. When was the last community needs assessment conducted that included suicide-specific information?

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* 25. If a community needs assessment was conducted, did it include suicide-specific information or was suicide prevention identified as a community priority or need?

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* 26. Are suicide prevention activities a part of the Coalition's comprehensive prevention plan?

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* 27. Does the Coalition support or implement any evidence-based programs or best practices relating to suicide prevention?

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* 28. What types of activities does your Coalition plan and support relating to suicide prevention?

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* 29. Does your Coalition have any paid staff?

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* 30. Please list the Coalition’s current funding sources:

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* 31. Indicate below if you would like to opt in to any of the below email lists or to receive follow-up information (select all that apply).

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* 32. Please check the box below if you consent to your Coalition information being shared.