Please note that all fields marked with an asterisk (*) are required to provide relevant and accurate reporting. These fields are not confidential in that they will be used for aggregate reporting purposes. For instance, it will be reported the number of males and females who have died by suicide, the number of states with the highest suicide rates, etc.
Items without asterisks are not required. If provided, this information is strictly confidential and will not be disclosed without prior consent.
If you wish to report the name of the first responder you may, this will help with the vetting process but will be kept confidential. At no time will this piece of information be shared without your permission. This is not required for reporting purposes.
Note: Contact information for the person reporting is requested so that we may ensure the information is accurate and reliable. We will not contact you unless absolutely necessary.
Gender (Required) Race Race Unknown American Indian or Alaska Native Asian Black or African American Caucasian Hispanic Rank Chief Executive (ex. Chief) Senor Executive (ex. Deputy Asst. / Asst. Chief ) Mid-Manager (ex. Division / Battalion / District Chief ) Line Supervisor (ex. Captain / Lieutenant / Sargeant ) Paramedic EMT On or Off Duty? At time of death Unknown On Duty Off Duty Military Veteran Marital Status Married Single Common Law Marriage Separated Widower Divorced Domestic Partner Engaged Life Partner Other Any Children? Did the first responder have children? Unknown Yes No Duty Status Active Admin Leave Fired FMLA Light Duty Medical Leave Medically Retired PTSD Leave Resigned Retired Suspended Terminated Unpaid Leave Other Manner of Death Firearm Hanging Vehicle Asphyxiation Drug Overdose Carbon Monoxide Other Had the person sought help? Was there a history of job related PTSD? Were there prior suicide attempts? Was this person under investigation at the time of death?
If available, and applicable, we appreciate any links to the death that can provide verification of the suicide or details about the firefighter. This includes a link to the obituary. All of this is kept confidential, no matter how public the suicide, unless the family provides permission to share.
Is there anything else you would like us to know?
On occasion, we send cards and small gifts, such as Christmas ornaments, to family members. Please add the mailing address, family relation type (parent, spouse...) and, any other information (names, ages and gender) below. Again, this information is not shared in any way and is solely used for support and remembrance.
Memorial Page I am a Spouse of Responder Sibling of Responder Parent of Responder Child of Responder Significant Other Friend Coworker Other FH Your contact information Can we contact you for more information if needed?
We will only contact you if there is something pressing that we feel we need to ask. For instance, if a future study requires more information. Otherwise, we will not contact you in any way.