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Surveys
2015
March
S
Suicide
Suicide
0%
Exit Survey
Hello: Thank you for taking time to participate in my survey on suicide. The purpose of the survey is to collect data for the book I'm writing on Suicide an Epidemic in America. The book is being written to help bring awareness to the epidemic at hand. The desire was put in me to help bring people out of darkness into the light. My goal is to shed light where there is no light, bring hope where there is no hope, and show love where there is no love.
Your participation in this study is completely voluntary. If you feel uncomfortable answering any questions, you can withdraw from the survey at any point. Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. Thank you very much for your time and support. Please start with the survey now by clicking on the
Continue
button below.
I Agree
Have you ever attempted suicide?
Yes
No
How did or do you want to hurt self?
Have you ever felt (Select all that apply)?
Depressed
Sad
Anxious
Worthless
Unloved
Broken on the inside
Like no one understands you
Hopeless
What does suicide mean to you?
Do you have a means to hurt self? if yes what method
Is suicide your last resort? if yes what else have you tried?
Are there recent stressors in your life?
Job loss
Eviction
Family Problems
Substance use
Homeless
Finance Problems
Abuse (physical or mental)
Care taker for mentally challenged or disabled child
Care taker for elderly parent /grandparent
Disappointment
Hurt
Tell me your story
Gender
Male
Female
Location
Midwest region
South region
East region
West region
Canada
Mexico
Age range
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+
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