Central Washington University has an investment in the welfare and well-being of all students. In its efforts to ensure the general well-being of all students, staff and faculty the university has implemented a suicide prevention program. The programs goal is to assess students that have engaged in suicide-related behavior in order to evaluate their level of risk and provide them with professional mental health services.

The Suicide Incident Report Form is used to inform the Suicide Prevention Team that a student has engaged in suicide-related behavior. Such suicide-related behavior can include making suicide threats verbally or nonverbally (e.g., through writing) as well as engaging in intentional self-injurious behavior with the intent to attempt suicide and/or to give the appearance of intending to kill him/herself.

Any concerned party can complete the Suicide Incident Report Form. Once the form is completed it is sent to the Suicide Prevention Team for review and disposition. If action is taken on the basis of the report, the student will be contacted by the Office of Student Affairs and Enrollment Management and directed to contact the Student Counseling Center for compulsory risk assessment. Again, the ultimate goal is to provide the student with mental health services in order to assist the student in developing more adaptive ways to cope and adjust to psychological stress and strain.

IDENTIFYING INFORMATION

Student's Name:
Student's Phone Number:
Student's Age:
Student's Gender:	Male Female Trans
Student's Academic Year: Fresh Soph Junior Senior Post-Grad Other Not Sure

INCIDENT INFORMATION

Incident Date:
Incident Time:
Incident Location:	On-Campus     Off-Campus
Nature of the Incident Please describe any threats made in which the student expressed intent to hurt him/herself but took no definitive action. Please descrive what you know about the nature of the threat itself and any events preceding the threat: Were actions taken representing intent to harm oneself? Please describe what took place: Once the threat and/or actions became known, what were the immediate responses?

BACKGROUND INFORMATION

To the best of your knowledge, has this student made prior threats or actions?

Yes   No   Unknown

Are there others able to provide additional information about the incident (e.g. roommate, friend, etc.)?
Name	Phone	Relationship to Student

Information about author of report:
Name:
Relationship to Student:
Dept., Agency, or Service:
Phone:
Date of Report:

Counseling Services Links Suicide Incident Report Form Confidentiality Counseling Center Staff Faculty Guide to: Assisting the Emotionally Troubled Student (A resource guide). Groups/Workshops Doctoral Internship Useful Resources