Event Information
|
Planned/premeditated |
Had orders to deploy |
Event type |
Observed and intervened |
Suicide event related to |
Suicide (suicide, suicide attempt, self
harm, suicidal ideation) |
Suicide note |
deployment |
Communicated self harm |
Describe additional relevant info |
Event date |
Primary motivation for suicidal |
|
Event time |
behavior for suicide behavior |
Personal History
|
|
Duty environment /status |
Victim of
|
Patient Information
|
Sequence of events |
Physical abuse or assault |
Name |
|
Sexual abuse or assault |
Social security number |
Medical History
|
Emotional abuse or assault |
Date of birth |
Seen in medical treatment |
Sexual harassment |
Sex |
facility |
Perpetrator of
|
Racial category |
Utilized substance abuse |
Physical abuse or assault |
Specific ethnic group |
services |
Sexual abuse or assault |
Current marital status |
Utilized family advocacy |
Emotional abuse or assault |
Education |
program |
Sexual harassment |
Religious preference |
Utilized chaplain services |
Life Stressors
|
Residence |
Utilized outpatient behavioral |
Childhood/developmental |
Resided alone |
health Utilized inpatient |
history |
Have minor children |
behavioral health |
History of
|
Involved in community support |
History of traumatic brain injury |
Failed intimate relationship |
|
List psychiatric diagnoses |
Failed relationship other |
Military Information
|
List psychotropic medications |
Spousal suicide |
Component/Military status |
Prior self injurious events |
Family suicide |
Primary job code |
Received suicide prevention |
Suicide by friend |
Working in primary job code |
trainings |
Death of spouse or family |
Duty status |
Elaborate on treatment history |
member |
Pay grade |
|
Death of friend |
Permanent duty station |
Military History
|
Physical health problem |
Permanent duty assignment |
Court martial proceedings |
Chronic spousal or family |
Unit identification code |
Article 15 |
severe illness |
Date of entry into the military |
Administrative separation |
Excessive debt or bankruptcy |
Date of rank |
proceedings |
Job problems |
Assigned to warrior transition |
AWOL/Unexcused absence |
Supervisor or coworker issues |
unit |
Medical evaluation board |
Poor work performance review |
Length of time in unit |
Civil legal problems |
or evaluation |
Geographic location of event |
Non-selection for advanced |
Unit or workplace hazing |
Setting |
schooling, promotion, or |
Family history of mental illness |
|
command |
Gun in home or immediate |
Event Information
|
Elaborate on life stressors |
environment |
Hospitalization (inpatient outpatient mental
health evaluation/treatment evacuation) |
|
Elaborate on additional details |
Deployment History
|
|
How many deployments |
Provider Information
|
Primary method used |
Deployment location (most recent last 3) |
Respondent's qualifications and
contact information |
Alcohol used during the event |
Start dates |
Drugs used during the event |
End dates |
Intended to die |
Rest & Recuperation Dates |
Self-inflicted injuries |
Obtained a waiver to deploy |
Death-risk gambling |
Experienced direct combat |