Community Readiness About Suicide Prevention - Pre Grant Cycle

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* 1. (Community Knowledge About Suicide Prevention) How much of a concern is suicide in your communities? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 2. Do you feel your communities have sufficient efforts, programs or activities related to suicide prevention? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 3. Are the programs efforts or activities sufficient to reduce suicide? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 4. If your communities have programs, efforts or activities, how aware are community members? please (rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 5. Do your communities have any protocols in effect related to suicide prevention? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 6. (Community Leadership) How much of a concern is suicide to the leadership in your communities? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10 ten ("all the time")

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* 7. Are the leaders in your communities involved in efforts to reduce suicide? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

Please describe:

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* 8. Would leadership in your communities support additional efforts, programs and activities? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ("all the time")

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* 9. (Community Climate) Is the communities' attitude about suicide prevention very positive? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 10. Are there any obstacles in your communities to impede efforts for suicide prevention? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

Please describe:

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* 11. How supportive or involved are the communities with suicide prevention efforts? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 12. (Knowledge) Is there information available to community members regarding suicide? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 13. Are community members knowledgeable about suicide prevelance, signs and symptoms of sucide? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 14. Is there sufficient data available about suicide in your communities? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 15. (Resources for Prevention) Are community members' attitude supportive for reducing suicide? (ie: people volunteer, make financial donations, provide space, etc.) (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

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* 16. Are you aware of any proposals or action plans that have been written to address suicide prevention? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time).

1. one ("not at all")

2. two

3. three

4. four

5. five

6. six

7. seven

8. eight

9. nine

10. ten ("all the time")

Please Describe:

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* 1. (Community Knowledge About Suicide Prevention) How much of a concern is suicide in your communities? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 2. Do you feel your communities have sufficient efforts, programs or activities related to suicide prevention? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 3. Are the programs efforts or activities sufficient to reduce suicide? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 4. If your communities have programs, efforts or activities, how aware are community members? please (rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 5. Do your communities have any protocols in effect related to suicide prevention? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 6. (Community Leadership) How much of a concern is suicide to the leadership in your communities? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 7. Are the leaders in your communities involved in efforts to reduce suicide? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 8. Would leadership in your communities support additional efforts, programs and activities? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 9. (Community Climate) Is the communities' attitude about suicide prevention very positive? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 10. Are there any obstacles in your communities to impede efforts for suicide prevention? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 11. How supportive or involved are the communities with suicide prevention efforts? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 12. (Knowledge) Is there information available to community members regarding suicide? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 13. Are community members knowledgeable about suicide prevelance, signs and symptoms of sucide? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 14. Is there sufficient data available about suicide in your communities? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 15. (Resources for Prevention) Are community members' attitude supportive for reducing suicide? (ie: people volunteer, make financial donations, provide space, etc.) (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time")

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* 16. Are you aware of any proposals or action plans that have been written to address suicide prevention? (please rate on a Scale from 1 to 10 with 1 being "not at all", 10 being "all the time).

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* 17. Additional Comments?

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* 18. What is your first name?

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* 19. What is your last name?

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* 20. What is the name of your Agency?

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* 21. What is Today's Date?