Suicide Reporting
Agency Name*: Name of Deceased*: Gender*: MaleFemaleOther Age*: Rank / Position*: IAFF Member*: —Please choose an option—YesNoUnknown Years of Service: City, State/Province, Country*: Additional Details REQUIRED* (Date of death or year if exact date is unknown – required, how suicide occurred, catalysts, stressors, work, relationships, behavioral health issues): Additional Comments: NOTE: Please complete the following fields ONLY if you wish to be contacted regarding this report: Phone Number: Email Address:
70386