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CONTENTS

FOREWORD ...................................................................................................................... vii


ACKNOWLEDGEMENTS ................................................................................................ ix
SUMMARY OF FINDINGS .............................................................................................. 1
CHAPTER I. BACKGROUND AND SCOPE ................................................................... 5
Scope……………………………………………………………………… .......................... 5
Methodology………………………………………………………………. ........................ 6
Findings and Recommendations…………………………………………… .................. 10
CHAPTER II. UNIVERSITY SETTING AND SECURITY............................................. 11
University Setting………………………………………………………….. ..................... 11
Campus Police and Other Local Law Enforcement.................................................. 11
Building Security…………………………………………………………......................... 13
Campus Alerting Systems………………………………………………… ..................... 14
Emergency Response Plan…………………………………………………..................... 15
Key Findings……………………………………………………………… ........................ 16
Recommendations………………………………………………………… ....................... 17
CHAPTER III. TIMELINE OF EVENTS………………………………………................... 21
Pre-Incidents: Cho’s History ...................................................................................... 21
The Incidents .............................................................................................................. 24
Post-Incidents ............................................................................................................. 29
CHAPTER IV. MENTAL HEALTH HISTORY OF SEUNG HUI CHO ......................... 31
PART A – MENTAL HEALTH HISTORY ................................................................ 31
Early Years………………………………………………………………… ....................... 31
Elementary School in Virginia…………………………………………….. ................... 33
Middle School Years ................................................................................................... 34
High School Years…………………………………………………………. ...................... 36
College Years………………………………………………………………........................ 40
Cho’s Hospitalization and Commitment Proceedings .............................................. 46
After Hospitalization……………………………………………………….. .................... 49
Missing the Red Flags................................................................................................ 52
Key Findings…………………………………………..…………………… ...................... 52
Recommendations…………………………………………………………. ...................... 53
PART B – VIRGINIA MENTAL HEALTH LAW ISSUES....................................... 54
Time Constraints for Evaluation and Hearing ......................................................... 55
Standard for Involuntary Commitment .................................................................... 56
Psychiatric Information ............................................................................................. 56
Involuntary Outpatient Orders ................................................................................. 58
Certification of Orders to the Central Criminal Records Exchange........................ 59
Key Findings............................................................................................................... 60
Recommendations ...................................................................................................... 60

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CHAPTER V. INFORMATION PRICACY LAWS………………………………................ 63
Law Enforcement Records…………………………………………………..................... 63
Judicial Records……………………………………………………………....................... 64
Medical Information................................................................................................... 65
Educational Records................................................................................................... 65
Government Data Collection and Dissemination Practices Act…………… ............ 67
Key Findings…………………………........................................................................... 68
Recommendations…………………………………………………………. ...................... 68
CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES………………….. ........... 71
Firearms Purchases………………………………………………………… .................... 71
Ammunition Purchases……………………………………………………...................... 74
Guns on Campus ........................................................................................................ 74
Key Findings……………………………………………………………….. ...................... 75
Recommendations………………………………………………………….. ..................... 76
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON………. .......... 77
Approach and Attack………………………………………………………. ..................... 77
Premature Conclusion?.................................................................................. ............ 79
Delayed Alert to University Community………………………………….................... 80
Decision not to Cancel Classes or Lock Down…………………………. ..................... 82
Continuing Events…………………………………………………………. ..................... 84
Motivation for First Killings?........................................................................ ............ 86
Key Findings……………………………………………………………….. ...................... 86
Recommendations………………………………………………………….. ..................... 87
CHAPTER VIII. MASS MURDER AT NORRIS HALL…………………………. ............. 89
The Shootings………………………………………………………………....................... 90
Defensive Actions…………………………………………………………. ....................... 92
Police Response……………………………………………………………........................ 94
University Messages………………………………………………………....................... 95
Other Actions on the Second and Third Floor……………………………................... 97
Action on the First Floor…………………………………………………… .................... 98
The Toll…………………………………………………………………….. ....................... 98
Key Findings............................................................................................................... 98
Recommendations………………………………………………………….. ..................... 99
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE… ......................... 101
West Ambler Johnston Initial Response…………………………………… ................ 101
Norris Hall Initial Response……………………………………………….. ................... 102
EMS Incident Command System………………………………………… ..................... 103
Hospital Response………………………………………………………… ....................... 110
Emergency Management………………………………………………….. ..................... 116
Key Findings……………………………………………………………….. ...................... 121
Recommendations………………………………………………………….. ..................... 122

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CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER………………............ 123
Legal Mandates and Standards of Care……………………………………. ................ 123
Death Notification………………………………………………………….. ..................... 124
Events………………………………………………………………………. ....................... 124
Issues……………………………………………………………………… ......................... 127
Key Findings……………………………………………………………….. ...................... 131
Recommendations………………………………………………………….. ..................... 132
A Final Word .............................................................................................................. 133
CHAPTER XI. IMMEDIATE AFTERMATH AND THE LONG ROAD TO HEALING 135
First Hours…………………………………………………………………........................ 136
Actions by Virginia Tech…………………………………………………… .................... 136
Meetings, Visits, and Other Communications with Families and
with the Injured...................................................................................................... 142
Ceremonies and Memorial Events………………………………………………............ 144
Volunteers and Onlookers……………………………………………………….. ............ 144
Communications with the Medical Examiner’s Office………………………….. ....... 145
Department of Public Safety……………………………………………………… .......... 145
Key Findings............................................................................................................... 145
Recommendations…………………………………………………………………............. 146

APPENDIX A – EXECUTIVE ORDER 53 (2007)............................................................ A-1


APPENDIX B – INDIVIDUALS INTERVIEWED BY RESEACH PANEL ................... B-1
APPENDIX C – PUBLIC MEETING AGENDA.............................................................. C-1
APPENDIX D – RECOMMENDATIONS ON REVIEW METHODOLOGY .................. D-1
APPENDIX E – VIRGINIA TECH GUIDELINES FOR CHOOSING
ALERTING SYSTEM ............................................................................ E-1
APPENDIX F – ACTIVE SHOOTER EXCERPT FROM UNIVERSITY OF
VIRGINIA EMERGENCY RESPONSE PLAN..................................... F-1
APPENDIX G – GUIDANCE LETTERS ON INTERPRETATION OF FERPA AND
HIPAA RULES FROM U.S. DEPARTMENT OF EDUCATION........ G-1
APPENDIX H – EXPLANATION OF FIRPA AND HIPAA LAWS ................................ H-1
APPENDIX I – FEDERAL AND VIRGINIA GUN PURCHASER FORMS .................. I-1
APPENDIX J – VIRGINIA FORM FOR INVOLUNTARY COMMITMENT
OR INCAPACITATION ........................................................................ J-1
APPENDIX K – ARTICLES ON MIXTURE OF GUNS AND ALCOHOL
ON CAMPUS ......................................................................................... K-1
APPENDIX L – FATAL SCHOOL SHOOTINGS IN THE UNITED STATES:
1966–2007. .............................................................................................. L-1
APPENDIX M – RED FLAGS, WARNING SIGNS AND INDICATORS....................... M-1
APPENDIX N - A THEORETICAL PROFILE OF SEUNG HUI CHO .......................... N-1