5431-E

SUICIDE PREVENTION EXHIBIT

Student Crisis Intervention Program

Suicide Incident Report

Student Name:______________________________________________________

School: ___________________________________________________________

Concern: __________________________________________________________

(What, When, Where)

__________________________________________ _______________________

Signature of Concerned Person Date

__________________________________________ _______________________

Signature of Principal Contacted about this Incident Date

Lethality Assessment Completed by:

Title: _____________________________________________________________

Action Taken: ______________________________________________________

Parent contacted by: _________________________________________________

Date: _____________________________________________________________

Title: _____________________________________________________________

Assessment Team Actions

Date Initials Comments on Actions Taken

(Please date all entries and be specific)

This document should be filed in a confidential file by the Building Principal.

Adoption date: January 1, 1993

Reviewed on:    November 25, 2003