Suicide Incident Report

If a student is in crisis and answers "Yes" to any of the following three 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?

If any of the questions above answer "Yes" please fill use the following form:

Student Information

Student Name
Age Gender

Incident Details

Date of Incident Time

Location

Nature of the Incident
  • Student made 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

Notes:

Information about the 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 the person used to hurt him/herself?
  • Were there any secondary means involved (alcohol, drugs, medication)? What were they??