Veteran: ______
Month Day Year Partner: ______ Participant ID
Visit: _________
SUICIDE & HOMICIDAL RISK ASSESSMENT – FOLLOW-UP ASSESSMENT
1a. Have you had any thoughts of wanting to hurt or kill yourself in the past month?
0 – No 1 – Yes
If NO, skip to #3a
1b. If YES to 1a, describe the thoughts: _____________________________________
____________________________________________________________________
____________________________________________________________________
1c. If YES to 1a, when did you have these thoughts in the past month? ___________
1d. If YES to 1a, did you have a specific plan, including the method, where, and when,
for how you would hurt or kill yourself? 0 – No 1 – Yes
If YES to 1d, complete CSRA
1e. If YES to 1d, Describe specific plan:________________________________
______________________________________________________________
______________________________________________________________
1f. Access to means: _______________________________________________
______________________________________________________________
1g. If YES to 1a, did you have intent to act on these thoughts? 0 – No 1 – Yes
If YES to 1g, complete CSRA
1h. If YES to 1g, Describe active intent: _______________________________
_____________________________________________________________
2a. Are you currently having thoughts of wanting to hurt or kill yourself? 0 – No 1 – Yes
If NO, skip to #3a
2b. If YES to 2a, describe the thoughts: _____________________________________
___________________________________________________________________
2c. If YES to 2a, do you have a specific plan, including the method, where, and when,
for how you would hurt or kill yourself? 0 – No 1 – Yes
If YES to 2c, complete CSRA
2d. If YES to 2c, Describe specific plan: ________________________________
______________________________________________________________
______________________________________________________________
Veteran: ______
Month Day Year Partner: ______ Participant ID
Visit: _________
2e. If YES to 2c, Access to means: ____________________________________
______________________________________________________________
2f. If YES to 2a, do you currently have any intent to act on these thoughts?
0 – No 1 – Yes
If YES to 2f, complete CSRA
2g. If YES to 2f, Describe active intent: _______________________________
______________________________________________________________
3a. Do you currently have any thoughts of killing another person? 0 – No 1 - Yes
If NO, stop here.
3b. If YES to 3a, describe the thoughts: _____________________________________
____________________________________________________________________
3c. If YES to 3a, do you have a specific plan for how you would go about this?
0 – No 1 – Yes
3d. If YES to 3c, describe the plan: ___________________________________
_____________________________________________________________
3e. If YES to 3c, access to means: ____________________________________
3f. If YES to 3a, do you have the intent to act on these thoughts? 0 – No 1 – Yes
3g. If YES to 3f, describe: ___________________________________________
______________________________________________________________