If a student is in crisis and answers yes to any of the following 3 questions, call 911 or campus safety at 459-5151 to transport them to a hospital.
Do you have a plan to harm yourself or someone else?
Do you have the means?
Have you set a day/time?
Otherwise fill out the following:
Student Name __________________________________________________ Age _____ Gender _____ College Year _____
Date of Incident___________________________________ Time ___________
1. Nature of the incident:
Student make a statement indicating suicidal thoughts or a threat to harm self or others, but did not take action
Student attempted to harm him/herself or another
Student died of apparent suicide
2. Information about Threat
Describe the events leading up to and surrounding the threat:
What was the nature of the threat? To whom was it made? Was it verbal or written? What was communicated?
Did the person have a plan? If so, what was it? Was there a secondary plan? What was it?
What was the primary means that t e person used to hurt him/herself?
Were there any secondary means involved (alcohol, drugs, medication)? What?
Submit this form to Paul Bennion, Dean of Students, firstname.lastname@example.org