Sucide Incitand Report Form – Fill Out and Use This PDF

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