Sucide Incitand Report Form PDF Details

In today’s increasingly complex and stressful academic environments, universities bear a significant responsibility in safeguarding the mental health and well-being of their students. The Suicide Incident Report Form, as utilized by the University of Illinois, exemplifies a proactive step towards this commitment. By enabling observers to document and alert the Counseling Center about students in a suicidal crisis, this form plays an essential role in prevention efforts. The comprehensive nature of the form covers not just personal data of the concerned student, including their academic standing and demographic details but extends to intricate aspects of any incident reported. Whether it involves threats, gestures, attempts, or actual suicide, the form encourages a detailed account, thereby facilitating a nuanced understanding and intervention strategy. Moreover, it seeks information on any preceding stressors, prior counseling, or suicide behaviors, as well as potential contacts who could offer further insights. By doing so, the Counseling Center can identify risk factors, tailor its response, and work collaboratively to encourage at-risk students to seek professional help. The ultimate aim of such a meticulously designed form is not only in immediate crisis management but also in contributing towards a broader strategy of identifying patterns and risk factors among the student population, thereby enhancing preventive measures against suicide.

QuestionAnswer
Form Name Suicide Incident Report Form
Form Length 2 pages
Fillable? Yes
Fillable fields 52
Avg. time to fill out 15 min
Other names doctoral, suicide report pdf, suicide report form

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Suicide Incident Report Form

The Counseling Center has a primary role in preventing suicide among University of Illinois students. By filling out this report you will be alerting the Counseling Center to the fact that a particular student was recently, or still is, in a suicidal crisis. The Counseling Center will then review your report and, if it seems necessary, will work with you to encourage the student to come in for counseling. The Counseling Center also uses these reports to identify “risk factors” that make certain students more prone to suicide than others.

I.PERSONAL DATA

1. Student’s Name: _____________________________________

 

 

(Last)

(First)

2.

Age:

_____ Race:

______________

3.

Sex:

Male

Female

4.Year in school (Please Check One):

 

Freshman

Masters

 

Sophomore

Doctoral

 

Junior

Professional

 

Senior

Don’t Know

 

Other (please specify):

______________________________

5.

College:

______________________________

6.

Major:

______________________________

7.

University ID #:

_______-_______-__________

II.INCIDENT INFORMATION

8.Date incident occurred: ____/____/_____

9.

Time incident occurred:

_____:00 a.m. or p.m.

10.

Location of incident:

______________________________

(room number/apartment number)

______________________________

(residence hall/street/city)

11. What was the nature of the incident? (check one)

Was it a threat in which the person expressed an intent to hurt him/herself but took no definite action? (If yes, please go to question 12.)

Was it a gesture or an attempt in which the person took some definite action? (If yes, please go to question 13.) Was it an actual or apparent suicide? (If yes, please go to question 13.)

12.Information about threats: (continue on other side if necessary)

a.Can you briefly describe the events leading up to and surrounding the threat? _________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

b. Was the threat verbal or written? To whom was it made?

______________________________________________________

______________________________________________________

c. Did the person have a plan? If so, what was it?

______________________________________________________

______________________________________________________

d. Did the person have the means to carry out the threats?

______________________________________________________

______________________________________________________

Please skip to question 14.

13.Information about gestures attempts and actual suicides: (continue on the other side)

a.Can you briefly describe what took place? _________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

b.What was the primary means that the person used to hurt

him/herself? ________________________________________

______________________________________________________

______________________________________________________

c. Were there any secondary means involved (e.g., alcohol, drugs, medication)? If medication was involved, where was it obtained?

______________________________________________________

______________________________________________________

d. How was the incident learned of? Did the person seek help? Did someone discover him/her? _____________________________

______________________________________________________

______________________________________________________

e. How was the incident handled? By whom? Please list the names of anyone involved: ___________________________________

______________________________________________________

______________________________________________________

______________________________________________________

III.BACKGROUND INFORMATION

14.In which of the following situations is the person living? (check one)

University residence hall Sorority/fraternity Other certified housing

Off-campus apartment or house

Other (please specify): ______________________________

15.Please indicate, to the best of your knowledge, which of the following stressors might have been present prior to the incident: (circle all that apply)

 

 

Not a

 

Very much

Don’t

 

 

problem

 

a problem

know

a.

Academic pressure

1

2

3

4

5

9

b.

Uncertain career future

1

2

3

4

5

9

c.

Social alienation

1

2

3

4

5

9

d.

Sexual problems

1

2

3

4

5

9

e.

Gay/lesbian issues

1

2

3

4

5

9

f.

Breakup with boy/girlfriend

1

2

3

4

5

9

g.

Difficulties with family

1

2

3

4

5

9

h.

Death/loss of family member/friend

1

2

3

4

5

9

i.

Financial matters

1

2

3

4

5

9

j.

Depression

1

2

3

4

5

9

k.

Loneliness

1

2

3

4

5

9

l.

Self-esteem problems

1

2

3

4

5

9

m.

Lack of friends

1

2

3

4

5

9

n.

Eating disorder

1

2

3

4

5

9

o.

Herpes or other VD

1

2

3

4

5

9

p.

Other (please describe)

1

2

3

4

5

9

________________________________________________

16.Prior counseling: Is this person currently receiving counseling or has he/she received counseling in the past? (check one)

Yes No Don’t Know

If yes, where, from whom, and for how long?

______________________________________________________

______________________________________________________

17.Prior suicide behavior:

a. Has this person made a previous threat, attempt, or gesture?

Yes No Don’t Know

a. If yes, please describe and give approximate dates:

______________________________________________________

______________________________________________________

______________________________________________________

c. How were these previous incidents handled? By whom?

______________________________________________________

______________________________________________________

______________________________________________________

18.Contacts:

Can you think of anyone who might be able to provide additional information about the incident (e.g., roommate, friend, residence personnel)?

______________________________________________________

(name)(phone number) (relationship to student)

______________________________________________________

(name)(phone number) (relationship to student)

______________________________________________________

(name)

(phone number)

(relationship to student)

19. Information about author of report:

a. Name:

___________________________________

b. Title or relationship

 

to the student:

___________________________________

c. Department:

___________________________________

d. Phone number(s):

___________________________________

e. Date of report:

___________________________________

Please mail or fax the report promptly to:

Dr. Paul Joffe

Counseling Center

212 Student Services Building

610 East John Street

Champaign, IL 61820

Phone – (217) 333-3704

Fax – (217) 244-7586

How to Edit Suicide Incident Report Form Online for Free

This guide will help you fill out the form accurately to capture all the information needed to take appropriate action.

1. Provide Personal Data

Start by entering the student's name, age, race, gender, year in school, college, major, and university ID. This section is used to identify the student involved in the incident and to access their academic or personal records.

2. Document the Incident

Record the date, time, and specific location of the incident. Describe the nature of the incident — whether it was a threat, a gesture, an attempt, or an actual suicide.

3. Detail the Incident

If it was a threat, describe the leading-up events, whether verbal or written, the intended recipient, and any plan or means to carry out the threat. If it was a gesture or an attempt, describe what occurred, the means used, any secondary means involved, and how the incident was handled.

4. Provide Background Information

Indicate the student's living situation and identify any stressors that might have been present before the incident. It could include academic pressure, social issues, or personal problems. Check if the student is currently receiving counseling or has a history of counseling and suicidal behavior.

5. Additional Information and Contacts

List contacts, such as roommates or friends, who might provide additional insights about the incident. Finally, fill in your details as the reporter, including your name, title, department, and contact information.

6. Submit the Report

Review the completed form for accuracy and completeness. Submit the report to the designated address at the Counseling Center either by mail or fax as provided on the form.

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