[All instructions (in RED) and text not applicable to the research should be deleted when the form is
modified for use on a particular study.]
This is an example template assessment and can be used as is by editing the highlighted text OR you
may design something similar in nature.
This brief assessment can be used in conjunction with other scales (e.g., SCID—Depression,
Hamilton Depression Scale, PHQ-9, etc.) that already have suicide questions. Thus, this assessment
is designed to probe the participant for further information, determine the best action plan, and to
document both the assessment and the steps taken.
SUICIDAL RISK ASSESSMENT
Only complete if the participant has answered the PHQ-9 suicide item with a
score of 1-3, indicating thoughts about hurting themselves (active suicidal
ideation) or thoughts that life is not worth living or that they would be better off
dead (passive suicidal ideation) at least several days over the past two weeks..
1. Can you tell me more about that? [Probe: What specifically have you been thinking
about? How frequently do you have these thoughts? How long do they stay on your
mind? If thoughts about hurting self: What makes you want to hurt yourself?]
For participants who report thoughts about hurting themselves (active suicidal ideation),
continue with the remainder of the assessment. Otherwise, go to Action Plan.
2. Right now, how strong is your wish to die?
None .................. 0
Weak ................... 1
Strong .................... 2
Don't Know.............. 7
Refused .................. 8
3. In the past month, have you made any plans or considered a method that you might
use to harm yourself?
No ................................... 0
Yes ................................... 1
Don't Know....................... 7
Refused .......................... 8
4. How much do you really intend to make a suicide attempt right now?
Not at all ....................0
Uncertain, not sure ...... 1
Certain ...................... 2
Don't Know...................7
Refused ...................8
SUICIDE RISK ACTION PLAN
LEVEL OF SUICIDE RISK ACTION PLAN
None Nothing
(PHQ-9 suicide item=0)
Mild Risk Nothing
o Passive suicidal ideation only
(No mention of thoughts of Return to interview.
actively hurting oneself in
question #1)
OR
o No or weak wish to die
(Question #2 = 0 or 1
AND Question #3 and #4 = 0)
Intermediate Risk: Reportable Let participant know that we will contact the
social worker/psychiatrist/psychologist to
o Strong wish to die inform them of the participant’s suicidal
(Question #2 = 2) thoughts/plans. Interviewer will notify social
worker immediately upon the end of the
BUT interview.
o No plan to harm self
(Question #3 = 0)
AND/OR
o No or uncertain intention to make
suicide attempt
(Question #4 = 0 or 1)
High Risk: Urgent In person: Explain to the participant that this
is the standard procedure for handling such
o Strong wish to die situations is to call 911. If necessary, you
(Question #2 = 2) may need to accompany the participant to
the emergency room.
AND
Phone screen: Keep participant on phone and
o Plan to harm self tell them that you are going to get someone
(Question #3 = 1) to call 911. From your office, signal a co-
worker and ask that they call 911 and explain
AND the situation. Stay on the phone with the
participant until help arrives.
o Intention to make suicide attempt
(Question #4 = 2)
