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Please answer each item carefully by selecting the number next to the statement that best applies to you.

1. 1.Have you ever thought about or attempted to kill yourself?

   • [1]1 — Never
   • [2]2 — It was just a brief passing thought
   • [3]3a — I have had a plan at least once but did not try to do it
   • [3]3b — I have had a plan at least once and really wanted to die
   • [4]4a — I have attempted to kill myself, but did not want to die
   • [4]4b — I have attempted to kill myself, and really hoped to die

2. 2.How often have you thought about killing yourself in the past year?

   • [1]1 — Never
   • [2]2 — Rarely (1 time)
   • [3]3 — Sometimes (2 times)
   • [4]4 — Often (3–4 times)
   • [5]5 — Very often (5 or more times)

3. 3.Have you ever told someone that you were going to commit suicide, or that you might do it?

   • [1]1 — No
   • [2]2 — Yes, at one time, but did not really want to die
   • [2]2 — Yes, at one time, and really wanted to die
   • [3]3 — Yes, more than once, but did not want to do it
   • [3]3 — Yes, more than once, and really wanted to do it

4. 4.How likely is it that you will attempt suicide someday?

   • [0]0 — Never
   • [1]1 — No chance at all
   • [2]2 — Rather unlikely
   • [3]3 — Unlikely
   • [4]4 — Likely
   • [5]5 — Rather likely
   • [6]6 — Very likely