FRA F 6180.125B Semi-structured Interview for Psychological Autopsy

Semi-structured Interview for Psychological Autopsy¹

The interviewer will NOT be asking these questions verbatim. Interviewers will be trained to conduct the interview in a manner that is sensitive and professional. Interviewees who do not speak English will be interviewed with the help of a translator. OMB No. 2130-XXXX

Case Number		Interview Date
Relationship of Informant to Decedent  Spouse  Father/Mother  Brother/Sister  Aunt/Uncle  Child  Other Relative	 Friend  Work Colleague/Employer  Classmate  Teacher  Other Specify:	ID Number of Interviewer
		Interview Venue
Comments:		Time Interview Started ______________ Time Interview Ended ______________

Demographic Information of decedent

1. Marital status at the time of death	 Married  Living together  Widowed – Since when? ______	 Divorced - When? ______ How many times? ______  Separated – When? ______  Never married
2. Feelings about marital status	 Happy  Unhappy	 No strong feelings  Don’t know
3. Place of birth (city, state, country)
4. Country of birth
5. Year when did decedent moved to the US?	Year:  N/A  Don’t know
5a. Was the decedent a US citizen	 Yes  No. Specify status in the US  Don’t know
6. Primary language
7. Race/Ethnicity	 White  Black  Hispanic  American Indian  Alaskan Native	 Asian  Pacific Islander  Other – Please Specify _______  Don’t know
8. Education status	 Never attended  Elementary school  Junior high school  High school  Some college	 College degree  Graduate or professional school  GED  Other – Please Specify _______  Don’t know
9. Raised by	 Adoptive parents  Foster parents  Biological parents	 Other – Specify:  Don’t know

Occupation and Employment

10. Employment status at time of death	 Full time  Part time  Retired	 Unemployed  Self employed
11. Occupation	 Laborer  Agriculture  Professional  Service industry  Government	 Homemaker  Subsistence  Railroad  Other – Specify:  Don’t know
12. Tenure at last job	 Less than one year  1 – 5 years  10 - 20 years	 20 – 30 years  30 years or more  Don’t know
13. Job satisfaction	 Happy  Unhappy	 No strong feelings  Don’t know
14. Any major negative job change in past 6 months	 Fired or Laid off  Demoted  Pay cut  Seasonal	 Health issues  Other – Specify:  None  Don’t know
15. Main source of income	 Job  Savings/Retirement  Public Assistance  Social Security  Spouse	 Parents  Other family members  Friends  Other – Please Specify _________  Don’t know
15a. Financial situation	 No financial pressure  Lived paycheck to paycheck  Other Specify:	 Significant Debt  Don’t Know

Religion and Religiosity

16. Religion
17. Was he/she active in his/her religion?	 Very active  Somewhat active	 Not active  Don’t know
18. Family expectations for religious practice	 Expected  Optional	 Other – Specify:  Don’t know
19. Attended religious services	 Daily  Once/week  Monthly	 Rarely  Don’t know
20. Change in participation in religious activities over past year	 Increase  Decrease	 Remained the same  Don’t know

Suicidal Desire

Symptoms

21. Symptoms or behaviors in weeks preceding death (check all that apply)	 Appeared sad, tearful, or moody  Displayed symptoms of depression. Describe:  Expressed suicidal ideation or thoughts of dying. Describe:  Appeared to have made a change for the better  Appeared anxious, or complained of anxiety or panic attacks  Appeared agitated  Behaved impulsively  Displayed uncontrolled rage or aggressive behavior  Demonstrated constricted thinking or “tunnel vision”  Disclosed feelings of guilt or shame  Appeared confused, disoriented, or psychotic  Expressed feelings of hopelessness, helplessness, or worthlessness  Showed an inflated sense of self or signs of magical thinking  Engaged in excessive risk-taking behaviors  Preparations for own death (e.g. updating will, insurance policies)  Expressed wish to reunite with a deceased one or to be reborn
22. Mental Status: Did decedent exhibit any of these in the last year of life?	 Impaired memory  Poor comprehension  Poor judgment  Hallucinations or delusions  Difficulty recognizing friends or family members
23. Precipitants to death (Check all that apply)	 Significant loss(es) – relationships, job, finances, prestige, self-concept, family member, moving, anything else important to deceased individual  Disruption of a primary relationship (real or perceived)  Legal troubles  Difficulties with police  Traumatic event  Significant life changes (negative as well as positive)  Suicide or suicide attempt by family member or loved one  Anniversary of a significant loss  Exposure to suicide of another (e.g. celebrity) through media or personal acquaintance

Physical Health

24. Any major health problems during his/her life	 Yes – Specify:  No  Don’t know
25. Seeing a doctor for any health problem in 6 months prior to death?	 Yes – Specify:  No  Don’t know
26. Did health problem change lifestyle?	 Yes – Specify how:  No  Don’t know

Emotional Reactivity

27. Over the course of his/her life, how many time did decedent:	Never	Once	Few times	Many times	Too many times	Don’t know
a. Throw a temper tantrum – screaming, slamming doors etc
b. Get into a physical fight with people
c. Get into verbal arguments with people
d. Deliberately hit another person or animal
e. Have discipline problems resulting in suspensions or expulsions
f. Have fights with bosses or supervisors that led to reprimands, demotions, or firing from job
g. Have difficulties with police that resulted in a warning, arrest, or conviction for a misdemeanor or felony
h. Do something that caused someone to complain to the police or to other family members

Lifestyle/Character

28. Would you describe the decedent as a perfectionist?	 Yes  No  Don’t know
29. Would you describe the decedent as rigid or very strict?	 Yes  No  Don’t know
30. Safety belt use during the last year of life	 Always  Sometimes  Never  Didn’t ride or drive in last year  Don’t know
31. Compared with most drivers, did the decedent drive	 A lot faster  A little faster  About the same speed  A little slower  A lot slower  Don’t know
31a. Any motor vehicle accidents in year prior to decedent’s death?	Describe:
32. Smoking behavior at time of death	 Yes – Specify how many packs each day  No  Don’t know
33. Duration of smoking behavior	 0-4 years  5-9 years  10-14 years  15 years or more  Don’t know
34. Was decedent trying to quit smoking at time of death?	 Yes  No  Don’t know
35. Did decedent ride a motorcycle, ATV, or snow mobile?	 Yes  No  Don’t know
36. Did decedent ever crash while riding a motorcycle, ATV, or snow mobile?	 Yes – Specify when, how many times  No  Don’t know
37. Did decedent wear helmet while riding ATV, snow mobile, or motorcycle?	 Never  Sometimes  Most of the time  Always  Don’t know
38. In the last 30 days of life, how often did decedent drive a car when he/she had been drinking alcohol	 Never  Once  2 - 4 times  5 or more times  Don’t know
39. Would you describe the decedent as impulsive?	 Yes  No  Don’t know
40. Gambling behavior	 Never  Sometimes  Often  Don’t know

Suicidal Capability

Psychiatric History

41. Prior suicidal attempts	 Yes – Describe each attempt: (Method, recency of attempt, any medical attention or hospitalization)  No  Don’t know
42. Hospitalization in psychiatric setting	 Yes – Describe where, when, diagnosis  No  Don’t know

Substance Abuse

43. Did he/she ever drink alcohol?	 Yes  No  Don’t know	If yes:  Daily  Weekly  Monthly  Other – Specify:
44. Binge drinking in the month prior to death	 Yes  No  Don’t know
45. History of drinking problem	 Yes  No  Don’t know
46. History of drug use (non-medication)	 Yes – Specify which drugs:  No  Don’t know
47. History of “accidental overdose”	 Yes – Specify when, which drug:  No  Don’t know
48. Under influence of alcohol or other drug at time of death	 Yes – Specify which drug:  No  Don’t know
49. History of blackouts after drinking	 Yes Describe how often:  No  Don’t know
50. History of arrests due to drinking or drug abuse	 Yes Specify when, which drug, how often:  No  Don’t know

Family History

51. Raised by either biological parent					 Yes Specify: Both parents or Single parent, Mother or Father  No  Don’t know
52. Family birth order					 Only child  First born  Second born  Third born				 Fourth born  Other – Specify:  Multiple birth – Specify:  Don’t know
53. Number of biological siblings					________				 Don’t know
54. Number of siblings dead					________				 Don’t know
55. Manner of sibling death
Sibling	Natural	Unintentional	Suicide		Homicide	Undetermined			Other	Don’t Know
#1
#2
#3
#4
56. Has decedent’s mother, father, or caregiver died					 Yes  No				 Don’t know
57. Manner of parents’/ caregivers’ death
Parent	Natural	Unintentional	Suicide	Homicide		Undetermined		Other		Don’t Know
Mother
Father
Caregiver 1
Caregiver 2
58. Family history of suicide			 Yes – Specify how many, who, method				 No  Don’t Know
59. Family history of mental illness			 Yes – Specify who, diagnosis				 No  Don’t Know

Firearm History

60. Did the decedent have access to or own a firearm?	 Yes - Specify when obtained:  No  Don’t know
61. Were any guns kept in or around decedent’s home in the year prior to his/her death?	 Yes  No  Don’t know
62. What types of guns did decedent have access to? (Check all that apply)	 Handgun  Shotgun  Rifle  Other – Specify:  Don’t know
63. Were the guns kept locked up?	 Yes  No  Don’t know
64. Did the firearms have a locking mechanism such as a trigger lock?	 Yes  No  Don’t know
65. Did the decedent have access to ammunition for the firearm?	 Yes  No  Don’t know
66. How familiar was decedent with firearms?	 Very familiar  Somewhat familiar  Not familiar at all  Don’t know

Suicidal Intent

Method of death

67. Would decedent have had knowledge and/or capability of assessing the degree of lethality of such an act?	 Yes  No  Don’t know
68. Distance of railroad from decedent’s residence
69. Presence of barriers to access train tracks	 Yes – Specify kind of barrier  No  Don’t know
70. Was suicide rehearsed or planned	 Yes  No  Don’t know
71. Did decedent give any opportunity to be rescued	 Yes – Specify  No  Don’t know
72. Did decedent have any relationship to the site of death?	 Yes – Specify  No  Don’t know
73. Did decedent leave a suicide note?	 Yes  No  Don’t know
74. Did decedent tell anyone that he was going to commit suicide?	 Yes – Specify whom  No  Don’t know

IV. Buffers/Connectedness

Access to Care

75. Received counseling in last year	 Yes. From whom? ________  No  Don’t know
76. Seen a therapist in last year	 Yes  No  Don’t know		If yes,  Psychologist  Psychiatrist  Social worker  School counselor  Other – Specify:  Don’t know
77. In therapy at the time of death	 Yes  No – Stopped when? __________  Don’t know
78. Receiving needed mental health care	 Yes  No  Don’t know	If no, why?  Didn’t believe in counseling or seeking help  Difficulty finding or getting into a facility  Difficulty finding or getting treatment  Problems getting help at home  Problems paying bills  Problems with transportation  No insurance coverage  Did not want help  Other – Specify:  Don’t know
79. Did you seek help for deceased individual	 Yes  No

Access to Medications

80. Any prescription medications used	 Yes – Specify Which medications, dosage?  No  Don’t know
81. Medications taken regularly	 Took as prescribed  Occasionally missed doses	 Frequently missed doses  Don’t know
82. Medications covered by insurance	 Yes  No  Don’t know
83. Trouble paying for medications	 Yes  No  Don’t know
84. Ease of obtaining medications	 Easy  Difficult	 Other – Specify  Don’t know

Social Supports/Attachments:

85. Number of close friends or relatives to talk freely to
86. Who could decedent count on to help him/her feel better when under pressure?	 No one  Relationship
88. Did decedent have a confidante?	 Yes. Specify:  No  Don’t know
89. Who accepted the decedent totally (best and worst points)	 No one Relationship
90. Who would help with daily chores if decedent was sick	 No one  Relationship
91. How satisfied was decedent with support received	 Very satisfied  Satisfied  Dissatisfied  Very dissatisfied

FRA F 6180.125B (1-07)

Public reporting burden for this information collection is estimated to average 120 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. According to the Paperwork Reduction Act of 1995, a federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with, a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 2130-XXXX. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: Information Collection Officer, Federal Railroad Administration, 1120 Vermont Ave., N.W., Washington D.C. 20590.

1 Blanca Guevara Werlanga and Neury José Botega, A semi-structured interview for psychological autopsy in suicide cases, Rev Bras Psiquiatr 2003;25(4):212-9