Suicidal Threats, Ideation, Attempts & Self-Harm

Please complete this form to the best of your knowledge.

Forward completed form to the Dean of Students office as soon as possible.

SECTION 1: STUDENT INFORMATION

Name:
Year in college:

Age _____
Frosh Soph

Junior

Senior

Grad

Gender: _____________________

Student ID #

SECTION 2: INCIDENT INFORMATION

Date:

Time: _____________ AM PM

Location:
1. Nature of the Incident (Circle one):
a. Student made a statement indicating suicidal thoughts or a threat to harm self, but did not take any
action. (If yes, please go to question 2.)
b. Student attempted to harm him/herself. (If yes, please go to question 3.)

2.

Information about Threat

a. Briefly describe the events leading up to and surrounding the threat:

b. What was the nature of the threat? To whom was it made? Was it verbal or written? What was
communicated?

c. Did the person have a plan? If so, what was it? Was there a secondary plan? What was it?

3. Was the student informed that a report would be made and the student should anticipate contact from
the Dean of Students Office?
Yes
No
Please continue onto next page

4. Information about self harming behaviors

a. Briefly describe what happened:

b. How was the incident discovered? Did the person seek help? From whom? Did someone discover
him/her? Who?

c. How was the incident handled? By whom? Please list the names of anyone involved.

OTHER RELEVANT INFORMATION (use additional sheets as needed and attach supportive
documents if available)

Reporter:
Title or relationship to student:
Department:

Revised 8-25-2014

Date Report Written:

email:
Phone Number:

_____
_______________________