Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires

Columbia Suicide Severity Rating Scale (NM800039)

Columbia Suicide Severity Rating Scale (NM800039) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires

Patient Name


MR #

NM800039 (Rev. 01/24/18) Worksheet Only – Not a Medical Record Document – DO NOT SCAN
UW Health
(University of Wisconsin Hospitals and Clinics Authority)

Ask questions that are bolded and underlined. YES NO
Ask Questions 1 and 2
1) Wish to be Dead:
Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not
wake up.

Have you wished you were dead or wished you could go to sleep and not wake up?

2) Suicidal Thoughts:
General non-specific thoughts of wanting to end one’s life/commit suicide, “I’ve thought about killing
myself” without general thoughts of way to kill oneself/associated methods, intent, or plan.

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) Suicidal Thoughts with Method (without Specific Plan or Intent to Act):
Person endorses thoughts of suicide and has thought of at least one method during the assessment
period. This is different than a specific plan with time, place or method details worked out. “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.”

Have you been thinking about how you might kill yourself?

4) Suicidal Intent (without Specific Plan):
Active suicidal thoughts of killing oneself and patient reports having some intent to act on such
thoughts, as opposed to “I have the thoughts but I definitely will not do anything about them.”

Have you had these thoughts and had some intention of acting on them?

5) Suicide Intent with Specific Plan:
Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent
to carry it out.

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

6) Suicide Behavior Questions:

Have you ever done anything, started to do anything, or prepared to do anything to end your
Examples: Collected pills, obtained a gum, gave away valuables, wrote a will or suicide note, 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; or actually took pills, tried to shoot yourself, cut yourself, tried to hang
yourself, etc.

If YES, ask: Was this within the past 3 months?

Past 3

For inquiries and training information contact: Kelly Posner, Ph.D.
New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York, 10032: posnerk@nyspi.columbia.edu
© 2008 The Research Foundation for Mental Hygiene, Inc.