Suicide Worksheet

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5/20 EXAMPLES

Text in this Example:

SUICIDE WORKSHEET
NAME OF DECEDENT:
This form is to completed in addition to the ROD form in these guidelines
INFORMANT:
(LAST)
(FIRST)
(MI)
ADDRESS:
CITY/STATE/ZIP:
CONTACT #:
RELATIONSHIP TO DECEDENT:
THE DECEDENT
RECENT MEDICAL COMPLAINTS:
NERVOUS DISORDERS
DEPRESSION - EXPLAIN:
HOSPITALIZATION HISTORY?
PREVIOUS SUICIDE ATTEMPTS?
EXPRESSIONS OF SUICIDAL INTENT?
CRIMINAL LITIGATION PENDING
CIVIL LITIGATION PENDING
EMPLOYMENT HISTORY & PROBLEMS IF ANY:
INSURANCE/INSURABILITY HISTORY:
HAS NEW INSURANCE BEEN PURCHASED RECENTLY?
DOES INSURANCE HAVE A SUICIDE CLAUSE:
MARITAL HISTORY - IF UNMARRIED, RELEVANT SOCIAL HISTORY:
FAMILY OR FRIEND PROBLEMS:
SCHOOL PROBLEMS, IF ANY:
HAS THERE BEEN A RECENT CHANGE IN THE DECEDENT'S LIFE OR CIRCUMSTANCES?
WHAT DID THE SUBJECT DO DIFFERENTLY ON THE DAY OF DEATH (THAT WAS USUALLY NOT
DONE ON THAT DAY OF THE WEEK OR HOUR OF THE DAY)?
EVIDENCE
IF SUICIDE NOTE IS PRESENT, WHERE IS IT FOUND:
WAS WRITING COMPARED TO OTHER WRITING BY THE DECEDENT AND VERIFIED?
WRITING IDENTIFIED BY:
RELATIONSHIP TO THE DECEDENT:
(EVERY EFFORT SHOULD BE MADE TO SEND THE SUICIDE NOTE IN WITH THE BODY WHEN BODY IS GOING IN FOR AUTOPSY. A COPY OF THE NOTE IS ALSO APPROPRIATE.)
NAME OF INVESTIGATOR
DMI#