Workplace Suicide Prevention Project Interest Form

We appreciate your interest in our workplace suicide prevention project! If you are interested in receiving more information about our project, please fill out this form.

Courses and training programs associated with this project are FREE for those meeting eligibility criteria:

You are a rural or Tribal North Dakota resident (i.e., resides anywhere in North Dakota except for Fargo, West Fargo, Bismarck, or Grand Forks); or
At least 50% of the people you serve and/or employ are rural or Tribal North Dakota residents.

All programs are offered virtually (to increase access). We also offer gatekeeper certification and instructor training in-person.

This project is supported by the Centers for Medicare & Medicaid Services (CMS) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $256,219.00 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the US Government.

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1. Your name: (Required.)

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2. Email (where we will send information and how we will contact you): (Required.)

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3. Which of the following apply to you (check all that apply):

For the purpose of this question, Rural or Tribal North Dakota resident is defined as residing anywhere in North Dakota EXCEPT for Grand Forks, Fargo, West Fargo, or Bismarck. (Required.)

I am a rural or Tribal North Dakota resident

At least 50% of the people I serve OR at least of 50% of the people I employ are rural or Tribal North Dakota Residents

None of the above apply to me

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4. Your organization, business, or institutional affiliation:

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5. Address where we can send more information (flyers, brochures, etc.):

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6. Would you like to meet with the Project Director (Dr. Erin Haugen) to discuss the project in greater detail, including plans for collaboration?

If yes, her email will come from erin@haugenperformance.com, so be sure to white list that email address!

Yes

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7. Which certification and/or training courses are you interested in (check all that apply)?

Note that gatekeeper training courses are 60-120 minutes long. Successful completion means participants are certified gatekeepers.

Instructor (T4T) courses are 8-10 hours long. Successful completion means participants can teach gatekeeper training courses within their organization. (Required.)

Continuing education and re-certification courses (1.5 to 3 hours, depending upon the course)

QPR suicide gatekeeper training tailored to your industry (2 hours)

QPR instructor (T4T) training (8-10 hours)

VitalCog in the Workplace gatekeeper training (2-4 hours)

VitalCog in Construction gatekeeper training (2-4 hours)

VitalCog instructor (T4T) training (8-10 hours)

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8. What format are you interested in (check all that apply)?

Please note that CE and re-certification courses associated with this project are pre-planned courses that are offered live & on-demand. If you want a CE or re-certification course specifically for, we can do that for a fee (that is outside of this project). (Required.)

In-person (at a location of your choice)

Virtual (via Zoom)

In-person (at a conference or other event)

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9. Approximately how many people do you want trained? If you selected multiple course types, please select total number trained across all courses. (Required.)

Workplace Suicide Prevention Project Interest Form

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* 1. Your name: (Required.)

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* 2. Email (where we will send information and how we will contact you): (Required.)

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* 3. Which of the following apply to you (check all that apply):For the purpose of this question, Rural or Tribal North Dakota resident is defined as residing anywhere in North Dakota EXCEPT for Grand Forks, Fargo, West Fargo, or Bismarck. (Required.)

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* 4. Your organization, business, or institutional affiliation:

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* 5. Address where we can send more information (flyers, brochures, etc.):

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* 6. Would you like to meet with the Project Director (Dr. Erin Haugen) to discuss the project in greater detail, including plans for collaboration?If yes, her email will come from erin@haugenperformance.com, so be sure to white list that email address!

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* 9. Approximately how many people do you want trained? If you selected multiple course types, please select total number trained across all courses. (Required.)

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* 10. Any questions or additional information you'd like to share that helps us assist you?

1. Your name: (Required.)

2. Email (where we will send information and how we will contact you): (Required.)

3. Which of the following apply to you (check all that apply):

For the purpose of this question, Rural or Tribal North Dakota resident is defined as residing anywhere in North Dakota EXCEPT for Grand Forks, Fargo, West Fargo, or Bismarck. (Required.)

4. Your organization, business, or institutional affiliation:

5. Address where we can send more information (flyers, brochures, etc.):

6. Would you like to meet with the Project Director (Dr. Erin Haugen) to discuss the project in greater detail, including plans for collaboration?

If yes, her email will come from erin@haugenperformance.com, so be sure to white list that email address!

9. Approximately how many people do you want trained? If you selected multiple course types, please select total number trained across all courses. (Required.)

10. Any questions or additional information you'd like to share that helps us assist you?