Form Unnumbered Law Enforcement Suicide Data Collection

Law Enforcement Suicide Data Collection

LESDC Pilot Questionnaire OPM - Copy

Law Enforcement Suicide Data Collection

OMB: 1110-0082

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Federal Bureau of Investigation

Uniform Crime Reporting Program

Law Enforcement Suicide

Data Collection







Suicide or Attempted Suicide










Version 1.0

Document Date: 8/10/2021


Prepared by:

Global Law Enforcement Support Section

Crime Statistics Management Unit

Uniform Crime Reporting Program






Definitions


Attempted suicide – A non-fatal act of self-harm behavior with an intent to die as a result of the behavior.

Former - Having previously occupied a particular role.

Incident – Occurrence of the suicide or attempted suicide.

Incident Date Date the incident occurred, or the beginning of the time-period in which it occurred, as appropriate.

Law enforcement agency – A federal, state, tribal, or local agency engaged in the prevention, detection, or investigation, prosecution, or adjudication of any violation of the criminal laws of the United States, a state, tribal, or a political subdivision of a state.


Law enforcement officer – Any current or former LEO (including corrections LEO) agent, or employee of the United States, a state, indian tribe, or a political subdivision of a state authorized by law to engage in, or supervise the prevention, detection, investigation, or prosecution of any violation of the criminal laws of the United States, a state, indian tribe, or a political subdivision of a state.


On dutyA LEO is working their assigned shift at the time of incident.


Off dutyA LEO who is not working their assigned shift at the time of incident.

Policy - A standard course of action that has been officially established by an organization, business, political party, etc.

Position Status - Job status of LEO at time of death.


Public Safety Telecommunicators - Operate telephone, radio, or other communication systems to receive and communicate requests for emergency assistance at a primary Public Safety Answering Point (PSAP) (9-1-1 Center) or a secondary (non-9-1-1 Center) PSAP emergency communications centers.


State - Each of the several states, the District of Columbia, and any commonwealth, territory, trust land or possession of the United States.

SuicideDeath caused by a self-harm behavior with an intent to die as a result of the behavior.

TraumaticEmotionally disturbing or distressing. Relating to or causing psychological trauma whether it is realized or not by the subject.


Law Enforcement Killed and Assaulted

Suicide Data Collection


This report is authorized by the Law Enforcement Suicide Data Collection Act, Title 34, § 50701 and Title 28, § 534, U.S. Code. Please use this form to report circumstances and other details regarding law enforcement officers who have attempted suicide or died by suicide. Information provided throughout this form should apply to data that was available at the time of form completion. The FBI will use this critical information for statistical purposes related to law enforcement, including research, training, and publication. Based on legislation requirements, data submitted within this questionnaire will be reported to the United States Congress and will be accessed on the Internet at https://fbi.gov/cde. Your accuracy, cooperation, effort, and time are critical to our mission and appreciated.


The goal of this collection is to develop, implement, collect, report, and maintain statistics on federal, state, local and tribal law enforcement suicides.


  • SUICIDE

  • ATTEMPTED SUICIDE


Are you the employing agency of the individual who attempted or committed suicide?

  • Yes (Business Rule: Move to Part I – Administrative Data (Employing Agency Info)

  • No (Business Rule – Move to next question)

Has an attempt to communicate this incident with the employing or previously employing agency been made?

  • Yes

  • No


PART I – ADMINISTRATIVE DATA


Investigating Agency: _______________________________________

Originating Identifier Number (ORI): ____________

Address:

________________________

______________________

_____________________


Street/PO Box

City/State

Zip Code

Telephone Number: (___) ________

Email Address: ____________________


Employing Agency:




Address:

________________________

______________________

_____________________


Street/PO Box

City/State

Zip Code

Telephone Number: (___) ________

Email Address: ____________________



Occupation of Individual:

Law Enforcement Agencies

Corrections

Legal System

Telecommunications (Check all that apply)

Supervisory/Management LEO Staff

Supervisory/Management

Advocate or Victim/Witness Specialist

Dispatcher

Sworn LEO

Sworn LEO Staff

Attorney (other than Prosecutor)

  • Fire

Supervisory/Management Staff (non-sworn)

Correctional Officers (not sworn LEOs)

Inspector

  • Emergency Medical Service

Professional Staff/Support Personnel

Investigators/Inmate Disciplinary Officers

Judge

  • Law Enforcement

Other: (list)

Community/Corrections Staff

Paralegal

Call Taker


Other: (list)

Parole Officer

Teletype Operator


Probation Officer

Professional Staff

Professional Staff (Other than those available for selection)


Prosecutor

Primary PSAP

Other

Secondary PSAP












PART II – PERSONAL DATA RELATIVE TO THE INCIDENT


Age at time of suicide or attempted suicide: ____________

Demographic:

Race: (choose all that apply – multi-race)


Male

White


Female

Black or African American


Non-binary

American Indian or Alaska Native


Other: (open text)

Asian



Native Hawaiian or other Pacific Islander



Hispanic or Latino



Total law enforcement work experience at time of incident:

Position Status:


0-5 years

6-10 years

11-15 years

16-20 years

21-30 years

Over 31 years

  • Actively Employed (Full time on duty)

  • Alternate work assignment

  • Family Medical Leave

  • Limited/Restricted Duty

  • On Approved Leave (annual/sick)

  • Part time employee

  • Reserve/In-training – Full time training duty.

  • Resigned

  • Retired – Withdrawn from occupation

  • Suspended – Out of work for disciplinary reasons.

  • Temporarily Separated (sabbatical) Terminated






Children:







  • Juvenile (child/grandchild/other) BUSINESS RULE: MOVE TO NUMBER OF CHILDREN

  • Adult (child/grandchild/other)

BUSINESS RULE: MOVE TO NUMBER OF CHILDREN

  • No

  • Unknown

Military Veteran:

Marital Status at time of incident:


Yes (BUSINESS RULE: MOVE TO BRANCH OF SERVICE)

Single/Never Married

Number of Children: (open text # only)

No (BUSINESS RULE: SKIP TO MARITAL STATUS)

Married


Unknown (BUSINESS RULE: SKIP TO MARITAL STATUS)

Divorced/Not Remarried



Divorced/Remarried


Branch of Service:

Widowed/Not Remarried


Air Force

Widowed/Remarried


Army

Separated


Coast Guard

Living with Significant Other


Marine Corps

Domestic partnership


Navy



























PART III – GENERAL DATA PERTAINING TO THE INCIDENT



Agency incident or case number: ________________________________________________________



Date of incident:


Time of incident:

  • Morning (6a-11:59a)

  • Afternoon (12p – 5:59p)

  • Evening (6p – 11:59p)

  • Night (12a – 5:59a)


Incident Occurred:

  • On Duty

  • Off Duty



Location of incident: _________________________________________________________________________________­­­­__

City County State Country




Type of location of incident:

  • Commercial

  • Government

  • Public space

  • Residential

  • Other location (specify) _________________


Manner of suicide or attempted suicide:

  • Firearm

  • Hanging

  • Overdose of prescription drugs

  • Overdose of illicit drugs

  • Alcohol

  • Knife/Cutting Instrument

  • Suffocation

  • Asphyxiation (i.e., ligature or carbon monoxide)

  • Jumping from high elevation

  • Death caused by what would otherwise be deemed accidental (specify/describe)

  • Purposely committing an act resulting in death

  • Other (specify)




Was this a murder/suicide or an attempted murder/suicide?

  • Yes (BUSINESS RULE: MOVE TO HOW MANY VICTIMS)

  • No (BUSINESS RULE: MOVE TO NOTICE QUESTION)

  • Unknown (BUSINESS RULE: MOVE TO NOTICE QUESTION)


How many victims? ________


Type of victims (choose all that apply)

  • Family Members

  • Coworkers

  • Strangers

  • Other (please explain)



Did the individual leave an explanation of the suicide or attempted suicide?

  • Yes (BUSINESS RULE: MOVE TO NEXT QUESTION)

  • No (BUSINESS RULE: MOVE TO NEXT SECTION)

  • Unknown (BUSINESS RULE: MOVE TO NEXT SECTION)




What type of explanation was left behind?

  • Note/written correspondence

  • Text message

  • Social media

  • Phone call/voice message

  • Video

  • Audio recording

  • Email correspondence

  • Other (Specify) _________________________________________




PART IV– CIRCUMSTANCES OF THE INCIDENT

Incident:

Did the individual report - or was known to have experienced - any of the following within the last year? (check all that apply)


YES

NO

UNKNOWN

Direct or Indirect involvement of an incident resulting in the death or serious injury of an individual

Experienced the death of a close colleague, friend, or family member

Survivors guilt

Threats of violence resulting from job performance results

Burnout/Secondary trauma collapse

Other (specify)


Individual Self-Reporting:

Did the individual report they (is/was) experiencing from any of the following? (check all that apply)


YES

NO

UNKNOWN

Post-traumatic stress disorder

Depression

Substance Use Disorder

Physical illness/injury impacting subject’s ability to perform in the capacity of the job.

Concern over impending retirement

Domestic violence

Chronic illness

Financial problems

Relationship problems

Compassion Fatigue

Vicarious Trauma

Other (specify)


Agency Awareness:

Are you aware if the individual exhibited any mental health/warning signs prior to the incident? (check all that apply)


YES

NO

UNKNOWN

Making threats to harm or kill themselves

Seeking abnormal access to drugs/weapons or other items that could cause harm

Excessively/consistently talking about death and/or dying

Expressing hopelessness, rage/anger, or anxiety

Engaging in risky behavior (reckless)

Increasing use of alcohol or drugs

Chronic/Increased absence from work

Increased work issues and/or complaints

Prior suicide attempts

Increased Social Isolation

No reports of any warning signs/None indicated to colleagues/agency

Other (specify)





Did the individual report a pending investigation against their employing agency? (BUSINESS RULE: APPLICABLE IF THE REPORTING AGENCY IS NOT THE EMPLOYING AGENCY)

  • Yes

  • No

  • Unknown


Is/was the individual(s) unit/office/division of employment under investigation? (BUSINESS RULE: APPLICABLE IF THE REPORTING AGENCY IS NOT THE EMPLOYING AGENCY)

  • Yes

  • No

  • Unknown


Was the individual the subject of a criminal investigation??

  • Yes

  • No

  • Unknown


Has/is the individual (been/being) charged for a crime?

  • Yes

  • No

  • Unknown


Was the individual the subject of an administrative investigation?

  • Yes

  • No

  • Unknown


Is/was the individual a witness in an investigation involving their colleague?

  • Yes

  • No

  • Unknown


Has the individual been disciplined (or pending discipline) for a violation of policy?

  • Yes

  • No

  • Unknown


Is/was the individual scheduled to stand trial, in civil, administrative, or criminal litigation, for an offense they allegedly committed?

  • Yes (BUSINESS RULE: PROCEED TO NEXT QUESTION)

  • No (BUSINESS RULE: SKIP TO “WAS THE INDIVIDUAL ON A PROMOTIONAL LIST)

  • Unknown (BUSINESS RULE: SKIP TO “WAS THE INDIVIDUAL ON A PROMOTIONAL LIST)


Would a guilty verdict preclude further service or employment by the individual?

  • Yes

  • No

  • Unknown


Was the individual on a promotional list?

  • Yes

  • No

  • Unknown


Was the individual recently denied a promotion or transfer?

  • Yes

  • No

  • Unknown

Was the individual recently demoted or moved to another assignment?

  • Yes

  • No

  • Unknown


PART V WELLNESS POLICY AND TRAINING

Does your agency have a formal well-being or resiliency program?

  • Yes

  • No

  • Unknown


Does your agency have a law enforcement competent formal well-being or resiliency program? (BUSINESS RULE: THIS QUESTION NEEDS TO BE APPLICABLE TO LEO AND CORRECTIONS – WILL NOT BE APPLICABLE TO LEGAL OR TELECOMMUNICATIONS)

  • Yes

  • No

  • Unknown


Does your agency provide training on secondary trauma, burnout, and suicide risk?

  • Yes

  • No

  • Unknown


Does your agency provide a peer-connection support program or platform?

  • Yes

  • No

  • Unknown


Does your agency provide training and opportunities for critical incident processing after significant traumatic work events?

  • Yes

  • No

  • Unknown


Does your agency provide mental health and counseling resources?

  • Yes

  • No

  • Unknown




Prepared by: ______________________________________________________ Date: ________/__________/__________

(mm/dd/yyyy)


Email address: ____________________________________________________ Telephone: _________________________


NOTE: If there are any questions concerning the completion of this form, contact the staff of the FBI UCR Program at 304‑625‑5370 or email at LESDC@fbi.gov.


Privacy Act Statement

Authority: The collection of this information is authorized under the Law Enforcement Suicide Data Collection Act, 34 U.S.C. § 50701; 28 U.S.C. § 534; 34 U.S.C. § 10211; 44 U.S.C. § 3101; and the general record keeping provision of the Administrative Procedures Act (5 U.S.C. § 301). Providing your contact information is voluntary; however, failure to provide your contact information may inhibit the FBI’s ability to verify or clarify information in your incident submission.

Principal Purpose: Providing your contact information allows the FBI to contact you with any clarifying questions regarding your submission. This allows the FBI to verify submitted information and ensure the accuracy of the data.

Routine Uses: All contact information will be maintained in accordance with the Privacy Act of 1974. Your information may be disclosed with your consent, and may be disclosed without your consent as permitted by all applicable routine uses as published in the Federal Register (FR), including the routine uses for The FBI Central Records System (JUSTICE/FBI-002), published at 63 FR 8659, 671 (Feb. 20, 1998) and amended at 66 FR 8425 (Jan. 31, 2001), 66 FR 17200 (Mar. 29, 2001), and 82 FR 24147 (May 25, 2017), and the FBI Online Collaboration Systems (JUSTICE/FBI-004), published at 82 FR 57291 (Dec. 4, 2017). Routine uses may include sharing information with other federal, state, local, tribal, or territorial law enforcement agencies.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKlingensmith, Lora L. (CJISD) (FBI)
File Modified0000-00-00
File Created2021-12-01

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