Exhibit 22 - Columbia Suicide Severity Rating Scale.pdf
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- Solicitation number
- BPM055260
- Issued by
- Baltimore City, Maryland
About this file
This document is an exhibit to a solicitation issued by an unspecified state or local agency for a Pre-Trial Diversion Services contract (Solicitation #BPM055260). Exhibit 22 provides the Columbia Suicide Severity Rating Scale (C-SSRS) Self-Report assessment tool, which appears to be a required screening instrument for the contract services. The C-SSRS is a clinical assessment form designed to evaluate suicide risk over the past month through six primary screening questions, with conditional follow-up questions if affirmative responses are given. The form includes fields for client identification (First Name, Last Name, SID/DOC#), clinician signature and date, and risk categorization (Low, Moderate, High Risk). The document includes the standard research reference for the C-SSRS and indicates the form version was developed in January 2026.
No specific pricing terms, contract amounts, set-asides, incumbents, funding sources, response dates, or other financial details are provided in this exhibit. The document serves solely as a standardized clinical tool specification for use within the contract's scope of work, likely requiring bidders and service providers to implement this assessment protocol as part of their service delivery to pre-trial populations.
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Text version
First Name Last Name SID/DOC#
OPS.XXX-XXX (Dev. 01/2026)
Columbia-Suicide Severity Rating Scale (C-SSRS)
Self-Report - Recent Screen Version - Recent Past month
Please answer questions 1 and 2 YES NO
1) Have you wished you were dead or wished you could go to sleep and not wake up?
2) Have you actually had any thoughts of killing yourself?
If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6.
3) Have you been thinking about how you might do this?
E.g. “I thought about taking an overdose 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.”
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.”
5) Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?
6) Have you ever done anything, started to do anything, or prepared to do anything to end your life?
Examples: Took pills, tried to shoot yourself, cut yourself, or hang yourself, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump, collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, etc.
If YES, ask: Was this within the past three months?
Low Risk Moderate Risk High Risk
Reference:
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J.
(2011). The Columbia–Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266–1277. https://doi.org/10.1176/appi.ajp.2011.10111704
Signed By: Client Clinician
Print Name Signature Date
DPDS-SUDTS (Pre-Trial) Solicitation #: BPM055260 Exhibit 22.
File details come from the government source that posted it. Updated .