Lewis and Clark Public Health QPR Pre-training Survey

Lewis and Clark Public Health QPR Pre-training Survey
Please provide the following information BEFORE you receive this Gatekeeper training. The anonymous information you provide will be used to assess the effectiveness of the training.

Your email address will be kept confidential and will not be used in any reporting. We are asking for your email address in order to combine your pre-training and post-training survey results.
1. Email*
example@example.com
2. QPR training date*

MonthDayYear
Date
3. Age*

14-17 years18-24 years25-44 years45-60 years61-80 years81 years or older
4. In what county do you currently live?*
5. In what county do you currently work?*
6. Gender*

FemaleMaleNonbinaryPrefer not to sayOther
7. Ethnicity*

Black or African AmericanAsian AmericanLatino/HispanicAmerican Indian or Alaska NativeWhite or CaucasianNative Hawaiian or other Pacific IslanderPrefer not to sayOther
8. Have you or a family member ever served in the military?*

YesNo
9. Are you attending this training for your role as a:*

Medical providerMental health providerFirst responder, e.g., firefighter, EMT, law enforcement, corrections (volunteer or professional)Other

10. How would you rate your knowledge of suicide in the following areas?*

	Low	Medium	High
Facts concerning suicide prevention
Warning signs of suicide
How to ask someone about suicide
Persuading someone to get help
How to get help for someone
Information about local resources for help with suicide

11. If you ask someone about suicide, you will plant the idea in their mind. They will then attempt to take their lives.*

Strongly disagreeDisagreeNeutralAgreeStrongly agree
12. People who die from suicide are weak and cowardly.*

Strongly disagreeDisagreeNeutralAgreeStrongly agree
13. If a person attempted suicide, survived and then received help, they are unlikely to die by suicide later.*

Strongly disagreeDisagreeNeutralAgreeStrongly agree
14. People who talk about suicide won’t do it. They’re just seeking attention.*

Strongly disagreeDisagreeNeutralAgreeStrongly agree
15. If a suicidal person plans to attempt suicide with a firearm but can’t get to one, they will just find some other way to die.*

Strongly disagreeDisagreeNeutralAgreeStrongly agree
16. Do you feel that asking someone about suicide is appropriate?*

AlwaysSometimesNever
17. Do you feel likely to ask someone if they are thinking of suicide?*

AlwaysSometimesNever

18. Before you take today's training, how would you rate your confidence in the following areas?*

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I feel confident in my level of understanding about suicide, suicide prevention and mental health.
I can recognize the signs a person may be dealing with a mental health problem, or suicidal crisis.
I feel prepared to help a person at-risk of suicide.
I can help a person who may be dealing with a mental health problem, or suicidal crisis by connecting them with resources.
I feel confident in my ability to recognize and correct mistaken beliefs about mental health, suicide, and mental illness as I come across them.

19. Since 2018, how many of the following training programs have you taken in Lewis and Clark County that are included in the following list: QPR (Question, Persuade, Refer); Youth Mental Health First Aid; Mental Health First Aid; Applied Suicide Intervention Skills Training (ASIST).*

None. This will be my first.I've taken one.I've taken two.I've taken three.I've taken four or more.
20. May we contact you in six months to inquire how the training has impacted you? The information you provide will help inform the future of this project.*

YesNo
21. Name

First NameLast Name
22. Phone Number
Please enter a valid phone number.
Should be Empty: