Lifelines Implementation Form

INSTRUCTIONS: Please complete one form per Implementation Group. An Implementation Group is defined as a group of students that received the same Lifelines lessons over the same time period. If different grades had the same Lifelines lessons in the same time period, they are considered to be an Implementation Group and one form can be filled out for all of them. You will be able to indicate that multiple grade-levels were in your group when completing the form.

School Name: (Select your county first, then select your school from the second drop down menu that appears.)

County
School Name

IMPLEMENTER'S First + Last name:

Implementer's email address:

Implementer's phone number with area code:

Start Date of Implementation: This question requires a valid date format of MM/DD/YYYY.

calendar

End Date of Implementation: This question requires a valid date format of MM/DD/YYYY.

calendar

What grade-levels did your Implementation Group consist of? (Select all that apply.)

Please select all components of the Lifelines program that were implemented to your group. (Select all that apply).

PART 1: Prevention
PART 2: Lifelines Intervention: Helping Students at Risk for Suicide
PART 3: Lifelines Postvention: Responding to Suicide and Other Traumatic Death

Total Number of Participants: This question requires a valid number format.

Number of students represented in the following age groups:
If no students in your group fit one of the below characteristics, please enter a 0.

	5 - 11 years
	12 - 14 years
	15 - 17 years
	Unknown
Total : 0

Number of students represented by Gender:
If no students in your group fit one of the below characteristics, please enter a 0.

	Female
	Male
	Other
Total : 0

Number of students represented by Ethnicity:
If no students in your group fit one of the below characteristics, please enter a 0.

	Hispanic
	Non Hispanic or Latino
Total : 0

Number of students represented by Race:
If no students in your group fit one of the below characteristics, please enter a 0.

	African American or Black
	American Indian or Alaskan Native
	Asian
	Middle Eastern
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Other
Total : 0

Number of students represented by Military Connection:
Please include any students with parents or family members currently serving in or retired/separated from the Armed Forces, the Reserves, or the National Guard.
If no students in your group fit one of the below characteristics, please enter a 0.

	Military
	Non Military
	Unknown
Total : 0