Record a Suicide Reporting Instructions: Our organization will be collecting Police & Correctional personnel suicide data to help assist in having accurate data and information demographics to assist with our research and Mission objectives. Badge of Life Canada is actively working with academics and research organizations, and key stakeholders on a long-term initiative to identify the tools required to support the recognition, prevention, intervention, and treatment of mental health concerns facing Canadian first responders and other public safety personnel. The collection of reliable and factual information permits us to advocate for the fallen member, their families, friends, and colleagues who ultimately all are affected by the loss. We request that anyone having information of a police or corrections suicide, to please complete this Confidential Record of Suicide Form. Research statistics will be utilized to identify such information as the number of males and females who have died by suicide, the statistical analysis by Province and job occupation/description without the disclosure of any name identification. We are mindful of the stigma surrounding suicide within police and correctional organizations and surviving family, colleagues and friends. We are aware of how some organizations wish to keep such information from public release for a variety of reasons. Any personal information submitted will remain confidential. The demographics submitted will in turn provide reliable and accurate statistics for future suicide prevention research. In closing, we honour and respect the privacy of the families and agencies involved. We have no intention to cause any undue pain or hardship through the collection of suicide statistics. Thank you in advance for your assistance and understanding. Name of Member Suicide* First Last Gender ** Female Male Date of Death* Date Format: MM slash DD slash YYYY Age at time of death **Years of Service*At Time of Death* On Duty Off Duty Unknown Were they previously a Military Veteran?* Yes No Were they*MarriedSingleDivorcedCommon-lawSeparatedOtherDid the officer have children?* Yes No If so, how many?Name of Police Service/Correctional Agency*Department ** Law Enforcement Corrections Occupation*Police OfficerSergeantDetectiveSenior OfficerForensicsSex Crimes UnitChild ExploitationProvincial CorrectionsFederal CorrectionsCorrectional Specialty UnitCourt ServicesPrisoner TransportSpecial ConstableCommunicator/dispatcherRecords ClerkAuxiliary OfficerWere they*Active DutyRetiredWorkers CompensationLong Term Disability CarrierSuspended with pay (facing discipline)Suspended without pay (facing discipline)City*Province*Country*Manner of Death (gunfire, overdose, etc.)*City & Province Geographic location of suicide?Had the individual sought professional help?*YesNoUnknownWas there a history of job related PTSD?*YesNoUnknownWere there any warning signs you were aware of?*Suicide threatsStatements revealing a desire to diePrevious suicide attemptsSudden changes in behaviour (withdrawal, apathy, moodiness)Depression (crying, sleeplessness, loss of appetite, hopelessnessFinal arrangements (giving away possessions)UnknownWas this individual under discipline investigation at time of death ?*YesNoUnknownWas there a media release about this loss?*YesNoUnknownName of media release publication (url link?)Is there anything else you would like us to know?Your Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last I am a*Family MemberFriendCo-workerOtherEmail* Can we contact you for more information if necessary?* Yes No CAPTCHAEmailThis field is for validation purposes and should be left unchanged.