Google Form Excel Spreadsheet to Track Student Responses to Universal Screening

Note: Use a Google Form to track the student responses to the Level 1 Universal Screening Questions

Column 1: Timestamp

Column 2: Email Address

Column 3: First Name, Last Name

Column 4: I choose to Opt-Out and not take the screen

Column 5: What is your grade level?

Column 6: What is your high school?

Column 7: What is the best way you can be reached today? (e.g. your cell phone, home phone) Please provide phone number or if you use an alternative email address.

Level 1 Screening Questions:

Column 8: 1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up?

Column 9: 2. In the past month, have you had any thoughts of killing yourself?

Column 10: 3. Have you been thinking about how you might do this? (E.g. “I thought about how to kill myself but I never made a specific plan as to when where or how I would actually do it….and I would never go through with it.”)

Column 11: 4. Have you had these thoughts and had some intention of acting on them? As opposed to “I have the thoughts but I definitely will not do anything about them.” 

Column 12: 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? 

Column 13: 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?

Column 14: 7. If yes, was this within the past 3 months?

Column 15: 8. Do you have a trusted adult in your life you can turn to for support?