Wish to be Dead

Have you wished you were dead or wished you could go to sleep and not wake up?

Active Suicidal Thoughts

Have you actually had any thoughts of killing yourself?

Suicidal Thoughts with Method

Have you been thinking about how you might do this?

Suicidal Intent (without Specific Plan)

Have you had these thoughts and had some intention of acting on them?

Suicidal Intent with Specific Plan

Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

Frequency of Suicidal Thoughts

How many times have you had these thoughts?

Duration of Suicidal Thoughts

When you have these thoughts, how long do they last?

Controllability of Suicidal Thoughts

Could/can you stop thinking about killing yourself or wanting to die if you want to?

Deterrents to Suicide

Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you from wanting to die or acting on thoughts of suicide?

Reasons for Suicidal Ideation

What sort of reasons did you have for thinking about wanting to die or killing yourself?

Actual Attempt

Have you made a suicide attempt? Have you done anything to harm yourself? Have you done anything dangerous where you could have died?

Yes

What did you do?

Did you______ as a way to end your life?

Did you want to die (even a little) when you_____?

Were you trying to end your life when you _____?

Or did you think it was possible you could have died from_____?

Or did you do it purely for other reasons, not at all to end your life or kill yourself?

Interrupted Attempt

Has there been a time when you started to do something to end your life but someone or something stopped you before you actually did anything?

Yes

What did you do?

Did you______ as a way to end your life?

Did you want to die (even a little) when you_____?

Were you trying to end your life when you _____?

Or did you think it was possible you could have died from_____?

Or did you do it purely for other reasons, not at all to end your life or kill yourself (like to relieve stress, feel better, get sympathy, or get something else to happen)?

Aborted or Self-Interrupted Attempt

Has there been a time when you started to do something to try to end your life but you stopped yourself before you actually did anything?

Yes

What did you do?

Did you______ as a way to end your life?

Did you want to die (even a little) when you_____?

Were you trying to end your life when you _____?

Or did you think it was possible you could have died from_____?

Or did you do it purely for other reasons, not at all to end your life?

Preparatory Acts or Behavior

Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)?

Yes

Please describe what steps you took

Non-Suicidal Self-Injurious Behavior

Have you engaged in any self-injurious behavior without intent to die? (e.g., cutting, burning, etc.)

Yes

Please describe the behavior and frequency

Suicide

Have you ever attempted suicide?

Yes

Please describe your experience

Most Recent/Most Lethal Attempt Details

Please provide the details of your most recent or most lethal attempt.

Actual lethality/Medical damage:

No physical damage or very minor physical damage (e.g., surface scratches) Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains) Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-degree burns; bleeding of major vessel) Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose with reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures) Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; third-degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area) Death

Potential Lethality

Potential lethality: Only answer if actual lethality=0 Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, had potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no medical damage; laying on train tracks with oncoming train but pulled away before run over)

Columbia-Suicide Severity Rating Scale (C-SSRS)

Instructions

Wish to be Dead

Have you wished you were dead or wished you could go to sleep and not wake up?

Active Suicidal Thoughts

Have you actually had any thoughts of killing yourself?

Suicidal Thoughts with Method

Have you been thinking about how you might do this?

Suicidal Intent (without Specific Plan)

Have you had these thoughts and had some intention of acting on them?

Suicidal Intent with Specific Plan

Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

Frequency of Suicidal Thoughts

How many times have you had these thoughts?

Duration of Suicidal Thoughts

When you have these thoughts, how long do they last?

Controllability of Suicidal Thoughts

Could/can you stop thinking about killing yourself or wanting to die if you want to?

Deterrents to Suicide

Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you from wanting to die or acting on thoughts of suicide?

Reasons for Suicidal Ideation

What sort of reasons did you have for thinking about wanting to die or killing yourself?

Actual Attempt

Have you made a suicide attempt? Have you done anything to harm yourself? Have you done anything dangerous where you could have died?

Interrupted Attempt

Has there been a time when you started to do something to end your life but someone or something stopped you before you actually did anything?

Aborted or Self-Interrupted Attempt

Has there been a time when you started to do something to try to end your life but you stopped yourself before you actually did anything?

Preparatory Acts or Behavior

Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)?

Non-Suicidal Self-Injurious Behavior

Have you engaged in any self-injurious behavior without intent to die? (e.g., cutting, burning, etc.)

Suicide

Have you ever attempted suicide?

Most Recent/Most Lethal Attempt Details

Please provide the details of your most recent or most lethal attempt.

Potential Lethality