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Suicide Prevention
Washington County Suicide Prevention Reporting Form
Washington County Suicide Prevention Reporting Form
Date
Reporting Agency
Ambulance
School
Counseling Agency
Hospital
Church
Health Department
Fire Department
Law Enforcement
Medical
Friend/Family
Other
Age
10
11-13
14-17
18-21
22-25
26-34
35-45
46-55
56-65
66
Sex
Male
Female
Washington County
Bartlesville
Copan
Dewey
Ramona
Ochelata
Vera
Ideation
No Plan
Vague Plan
Specific Plan
Attempt
1st
2nd
3rd
4th or more
Attempted Method
Overdose/Poisoning
Stabbing/Cutting
Vehicular
Firearm
Suffocation/Hanging
Jumping
Other
Completion Date
Completion Method
Overdose/Poisoning
Stabbing/Cutting
Vehicular
Firearm
Suffocation/Hanging
Jumping
Other
Referral Made
Yes
No
Referred To
Counseling Center
Private Counselor
Physician
Pastor
Other
Postvention Provided (support offered after a suicide completion)
Yes
No
Did the individual go to ER?
Yes
No
Was the individual hospitalized?
Yes
No
What Hospital
Does the individual have a history of
hospitalizations in the last year?
Yes
No
Precipitating Factors - Select all that apply.
Financial
Mental Illness
Chronic Illness
Relationship Issues
Job Loss / Issues
Death of a loved one due to suicide
Homeless
Gay / Lesbian / Transgender
Substance Abuse / Alcohol
School Issues
Compulsive Gambling
Additional Comments