DoDSER Suicide Event Report

*** SENSITIVE INFORMATION / CLOSE HOLD ***

DoDSER

Department of Defense Suicide Event Report

OMB Control Number: 0704-XXXX

Expiration Date: XX/XX/20XX

Privacy Notice

This document contains confidential protected health information (PHI) and privileged information protected from release and disclosure by HIPAA, the Privacy Act, and FOIA exemption 6 (5 U.S.C. (b)(6)). Any unauthorized review, use, disclosure or distribution is prohibited.

Personal Information

1 Event type

• Death by suicide

• Attempt – evidence of intent to die

• Self-harm – without intent to die

• Ideation only – without an attempt/self-harm

[NONFATAL EVENTS ONLY] Has the patient been interviewed prior to or during the completion of this DoDSER?

• Yes

[IF YES] Are you the provider who interviewed the patient for this DoDSER?

• Yes

• No

• No

2 Event date: {MM/DD/YYYY}

Event time: {HH:MM}

• Check this box if date of death differs from the date of the injury

[SUICIDE ONLY – IF DIFFERENT FROM “EVENT DATE”] Date of death: {MM/DD/YYYY}

3 Last name: {FREE TEXT}

First name: {FREE TEXT}

Full middle name: {FREE TEXT}

Social security number: {0-9}{0-9}{0-9}-{0-9}{0-9}-{0-9}{0-9}{0-9}{0-9}

Verify social security number: {0-9}{0-9}{0-9}-{0-9}{0-9}-{0-9}{0-9}{0-9}{0-9}

4 Date of birth: {MM/DD/YYYY}

5 Gender:

• Male

• Female

6 Specify ethnic group:

• Hispanic or Latino – a person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race

• Not Hispanic or Latino– anyone with a known ethnicity not fitting the definition of Hispanic/Latino

• Data unavailable

7 Racial category (Mark all that apply):

• American Indian or Alaska Native - A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition

• Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, Thailand, or Vietnam

• Black or African American - A person having origins in any of the black racial groups of Africa

• Native Hawaiian/Other Pacific Islander - A person having origins in any of the original people of Hawaii, Guam, Samoa, or other Pacific Islands

• White - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East

• Data Unavailable

8 Current marital status:

• Never married

• Married

[IF MARRIED]

• Resides with spouse

• Separated due to relationship issues

• Separated due to other reasons (e.g., deployed)

• Data unavailable

• Legally separated

• Divorced

• Widowed

• Other [Specify: {FREE TEXT}]

• Data unavailable

9 Education:

• Some high school, did not graduate

• GED

• High school graduate

• Some college or technical school, no degree or certificate

• Four-year college degree

• Master’s degree or greater

• Data unavailable

10 Religious preference:

• American Baptist Churches

• Anglican Orthodox Church

• Assemblies of God

• Atheist

• Baptist

• Buddhism

• Christian Methodist Episcopal Church

• Christian Reformed Church

• Christian Science

• Christian – No Denominational Preference

• Church of Jesus Christ of Latter Day Saints (LDS)

• Church of Nazarene

• Churches of Christ

• Disciples of Christ

• Eastern Orthodox

• Episcopal

• Hindu

• Jewish

• Jewish Reform

• Jewish – Conservative

• Lutheran

• Lutheran Council

• Methodist

• Muslim

• Pentecostal

• Presbyterian

• Protestant

• Protestant – No Denominational Preference

• Reformed Episcopal Church

• Reorganized Latter Day Saints

• Roman Catholic

• Seventh-Day Adventist (SDA)

• Southern Methodist Church

• United Methodist

• United Presbyterian Church

• Wicca

• Other [Specify: {FREE TEXT}]

• No Preference

11 Residence at time of event:

• Barracks, tents, or other shared military living environment

• Bachelor Enlisted Quarters (BEQ) or Bachelor Officer Quarters (BOQ)

• On-base family housing

• Service member’s own owned or leased apartment or house of-base

• Ship

• Other [Specify: {FREE TEXT}]

• Data unavailable

12 Was the patient/decedent in a state of transition (recent, current, or upcoming within 90 days), including events such as deployment, geographic move, separation, and retirement?

• Yes

• No

• Data unavailable

13 Did the patient/decedent reside alone at the time of the event?

• Yes

• No

• Data unavailable

14 Did the patient/decedent have minor children?

• Yes

[IF YES] Were the children residing with him/her?

• Yes

• No

• Data unavailable

• No

• Data unavailable

15 Was the patient/decedent involved in community support systems (e.g., church/religious/spiritual groups, community organizations)?

• Yes

[IF YES] Please describe the patient’s/decedents’ involvement in community support systems. {FREE TEXT}

• No

• Data unavailable

16 Component/Military status

• Regular

• Reserve – (e.g., USAR, USMCR)

• National Guard [USAF & USA ONLY]

17 Primary job code

[USAF]

• 1A0X1 In-Flight Refueling

• 1A1X1 Flight Engineer

• 1A2X1 Loadmaster

• 1A3X1 Airborne Communications Systems

• 1A4X1 Airborne Battle Management

• 1A5X1 Airborne Missions Systems

• 1C0X1 Airfield Management

• 1C0X2 Operations Resource Management

• 1C1X1 Air Traffic Control

• 1C2X1 Combat Control

• 1C3X1 Command Post

• 1C4X1 Tactical Air Command and Control

• 1C5X1 Aerospace Control and Warning Systems

• 1C6X1 Space Systems Operations

• 1N0X1 Intelligence Applications

• 1N1X1 Imagery Analysis

• 1N2X1 Signals Intelligence Production

• 1N3X1 Germanic Cryptologic Linguist

• 1N3X2 Romance Cryptologic Linguist

• 1N3X3 Slavic Cryptologic Linguist

• 1N3X4 Far East Cryptologic Linguist

• 1N3X5 Mid-East Cryptologic Linguist

• 1N4X1 Signals Intelligence Analysis

• 1N5X1 Electronic Signals Intelligence Exploitation

• 1N6X1 Electronic System Security Assessment

• 1S0X1 Safety

• 1T0X1 Survival, Evasion, Resistance, and Escape Training

• 1T1X1 Aircrew Life Support

• 1T2X1 Pararescue

• 1W0X1 Weather

• 2A0X1 Avionics Test Station and Components

• 2A1X1 Avionics Sensors Maintenance

• 2A1X2 Avionics Guidance & Control Systems

• 2A1X3 Communication & Navigation Systems

• 2A1X4 Airborne Surveillance Radar Systems

• 2A1X7 Electronic Warfare Systems

• 2A3X1 F-15/F-111 Avionics Systems

• 2A3X2 F-16, F-117, CV-22 Avionic Systems

• 2A3X3 Tactical Aircraft Maintenance

• 2A4X1 Aircraft Guidance & Control

• 2A4X2 Aircraft Communication & Navigation Systems

• 2A5X1 Aerospace Maintenance

• 2A5X2 Helicopter Maintenance

• 2A5X3 Bomber Avionics Systems

• 2A6X1 Aerospace Propulsion

• 2A6X2 Aerospace Ground Equipment

• 2A6X3 Aircrew Egress Systems

• 2A6X4 Aircraft Fuel Systems

• 2A6X5 Aircraft Hydraulic Systems

• 2A6X6 Aircraft Electrical and Environmental Systems

• 2A7X1 Aircraft Metals Technology

• 2A7X2 Nondestructive Inspection

• 2A7X3 Aircraft Structural Maintenance

• 2A7X4 Survival Equipment

• 2E0X1 Ground Radar Systems

• 2E1X1 Satellite and Wideband Communications Equip

• 2E1X2 Meteorological and Navigation Systems

• 2E1X3 Ground Radio Communications

• 2E1X4 Visual Imagery and Intrusion Detection Systems

• 2E2X1 Electronic Computer and Switching Systems

• 2E3X1 Secure Communication Systems

• 2E4X1 Space Systems

• 2E6X1 Communications Antenna Systems

• 2E6X2 Communication Cable Systems

• 2E6X3 Telephone Systems

• 2E8X1 Instrumentation and Telemetry

• 2F0X1 Fuels

• 2G0X1 Logistics Plans

• 2M0X1 Missile and Space Systems Elect Maintenance

• 2M0X2 Missile and Space Systems Maintenance

• 2M0X3 Missile and Space Facilities

• 2P0X1 Precision Measurement Equipment Laboratory

• 2R0X1 Maintenance Data Systems Analyst

• 2R1X1 Maintenance Scheduling

• 2S0X1 Supply Management

• 2S0X2 Supply Systems Analyst

• 2T0X1 Traffic Management

• 2T1X1 Vehicle Operations

• 2T2X1 Air Transportation

• 2T3X1 Special Purpose Vehicle and Equipment Maint

• 2T3X2 Special Vehicle Maintenance

• 2T3X4 General Purpose Vehicle Mechanic

• 2T3X5 Vehicle Body Maintenance

• 2T3X7 Vehicle Maintenance Control & Analysis

• 2W0X1 Munitions Systems

• 2W1X1 Aircraft Armament Systems

• 2W2X1 Nuclear Weapons

• 3A0X1 Information Management

• 3C0X1 Communication-Computer Systems Operations

• 3C0X2 Comm-Computer Systems Programming

• 3C1X1 Radio Communications Systems

• 3C1X2 Electromagnetic Spectrum Management

• 3C2X1 Communication-Computer Systems Control

• 3C3X1 Comm-Comp Sys Planning & Implementation

• 3E0X1 Electrical

• 3E0X2 Electrical Power Production

• 3E1X1 Heating, Ventilation, AC, & Refrigeration

• 3E2X1 Pavement and Construction Equipment

• 3E3X1 Structural

• 3E4X1 Utilities Systems

• 3E4X2 Liquid Fuel Systems Maintenance

• 3E4X3 Environmental

• 3E5X1 Engineering

• 3E6X1 Operations Management

• 3E7X1 Fire Protection

• 3E8X1 Explosive Ordnance Disposal

• 3E9X1 Readiness

• 3H0X1 Historian

• 3M0X1 Services

• 3N0X1 Public Affairs

• 3N0X2 Radio and Television Broadcasting

• 3N1X1 Regional Band

• 3N2X1 Premier Band

• 3P0X1 Security Forces

• 3S0X1 Personnel

• 3S0X2 Personnel Systems Management (PSM)

• 3S1X1 Military Equal Opportunity

• 3S2X1 Education and Training

• 3U0X1 Manpower and Quality Management

• 3V0X1 Visual Information

• 3V0X2 Still Photographic

• 3V0X3 Visual Information Production-Documentation

• 4A0X1 Health Services Management

• 4A1X1 Medical Materiel

• 4A2X1 Biomedical Equipment

• 4B0X1 Bioenvironmental Engineering

• 4C0X1 Mental Health Service

• 4D0X1 Diet Therapy

• 4E0X1 Public Health

• 4F0X1 Aeromedical

• 4H0X1 Cardiopulmonary Laboratory

• 4J0X1 Occupational Therapy

• 4J0X2 Physical Therapy

• 4M0X1 Aerospace Physiology

• 4N0X1 Medical Service

• 4N1X1 Surgical Service

• 4P0X1 Pharmacy

• 4R0X1 Diagnostic Imaging

• 4T0X1 Medical Laboratory

• 4T0X2 Histopathology

• 4T0X3 Cytotechnology

• 4U0X1 Orthotic

• 4V0X1 Optometry

• 4Y0X1 Dental Assistant

• 4Y0X2 Dental Laboratory

• 5J0X1 Paralegal

• 5R0X1 Chaplain Service Support

• 6C0X1 Contracting

• 6F0X1 Financial Management & Comptroller

• 7S0X1 Special Investigations

• 10C0 Operations Commander

• 11BX Bomber Pilot

• 11EX Test Pilot

• 11FX Fighter Pilot

• 11GX Generalist Pilot

• 11HX Helicopter Pilot

• 11KX Trainer Pilot

• 11MX Mobility Pilot

• 11RX Recce/Surv/Elect Warfare Pilot

• 11SX Special Operations Pilot

• 11UX Remotely Operated Aircraft

• 12BX Bomber Navigator

• 12EX Test Navigator

• 12FX Fighter Navigator

• 12GX Generalist Navigator

• 12KX Trainer Navigator

• 12MX Mobility Navigator

• 12RX Recce/Surv/Elect Warfare Navigator

• 12SX Special Operations Navigator

• 12UX Remotely Operated Aircraft

• 13AX Astronaut

• 13BX Air Battle Manager

• 13DX Control and Recovery

• 13MX Airfield Operation

• 13SX Space & Missile

• 14NX Intelligence

• 15WX Weather

• 16FX Foreign Area

• 16GX Air Force Operations Staff Officer

• 16PX Intl Politico-Military Affairs

• 16RX Planning & Programming

• 20C0 Logistics Commander

• 21AX Aircraft Maintenance

• 21BX Maintenance

• 21MX Munitions and Missile Maintenance

• 21RX Logistics Readiness

• 30C0 Support Commander

• 31PX Security Forces

• 32EX Civil Engineer

• 33C0 Communications Commander

• 33SX Communications and Information

• 34MX Services

• 35BX Band

• 35PX Public Affairs

• 36MX Mission Support

• 36PX Personnel

• 38MX Manpower

• 40C0 Medical Commander

• 41AX Health Services Administrator

• 42BX Physical Therapist

• 42EX Optometrist

• 42FX Podiatrist

• 42GX Physician Assistant

• 42NX Audiology/Speech Pathologist

• 42PX Clinical Psychologist

• 42SX Clinical Social Worker

• 42TX Occupational Therapist

• 43AX Aerospace Physiologist

• 43BX Biomedical Scientist

• 43DX Dietitian

• 43EX Bioenvironmental Engineer

• 43HX Public Health

• 43MX Medical Entomologist

• 43PX Pharmacist

• 43TX Biomedical Laboratory

• 43VX Veterinary Clinician

• 43YX Health Physicist

• 44AX Chief, Hospital/Clinic Services

• 44BX Preventive Medicine

• 44DX Pathologist

• 44EX Emergency Services Physician

• 44FX Family Physician

• 44GX General Practice Physician

• 44HX Nuclear Medicine Physician

• 44JX Clinical Geneticist

• 44KX Pediatrician

• 44MX Internist

• 44NX Neurologist

• 44PX Psychiatrist

• 44RX Diagnostic Radiologist

• 44SX Dermatologist

• 44TX Radiotherapist

• 44UX Occupational Medicine

• 44YX Critical Care Medicine

• 44ZX Allergist

• 45AX Anesthesiologist

• 45BX Orthopedic Surgeon

• 45EX Ophthalmologist

• 45GX OB/GYN

• 45NX Otorhinolaryngologist

• 45PX Physical Medicine Physician

• 45SX Surgeon

• 45UX Urologist

• 46AX Nurse Administrator

• 46FX Flight Nurse

• 46GX Nurse-Midwife

• 46MX Nurse Anesthetist

• 46NX Clinical Nurse

• 46PX Mental Health Nurse

• 46SX Operating Room Nurse

• 47BX Orthodontist

• 47DX Oral and Maxillofacial Pathologist

• 47EX Endodontist

• 47GX Dentist

• 47HX Periodontist

• 47KX Pediatric Dentist

• 47PX Prosthodontist

• 47SX Oral Surgeon

• 48AX Aerospace Medicine Specialist

• 48GX General Medical Officer (GMO)

• 48RX Residency Trained Flight Surgeon

• 48VX Pilot-Physician

• 51JX Judge Advocate

• 52RX Chaplain

• Other [Specify: {FREE TEXT}]

• Data unavailable

[USA]

• 9 Officer Candidates

• 11 Infantry

• 12 Engineer

• 13 Field Artillery

• 14 Air Defense Artillery

• 15 Aviation

• 18 Special Forces

• 19 Armor

• 21 (62b) Corps Of Engineers

• 24 Telecommunications Systems Engineering

• 25 Communications And Information Systems Operation

• 25 Signal Corps

• 27 Paralegal

• 29 Electronic Warfare

• 30 Information Operations

• 31 Military Police

• 33 Electronic Warfare

• 34 Strategic Intelligence

• 35 Military Intelligence

• 36 Financial Management

• 37 Psychological Operations

• 38 Civil Affairs (Aa And Usar)

• 40 Space Operations

• 44 Finance

• 42 Adjutant General Corps

• 45 Armament Maintenance

• 46 Public Affairs

• 47 Usma Stabilized Facility

• 48 Foreign Area Officer

• 49 Operations Research/Systems Analysis

• 50 Force Management

• 51 Acquisition, Logistics And Technology

• 71 Laboratory Sciences

• 72 Preventive Medicine Sciences

• 73 Behavioral Sciences

• 74 Chemical, Biological Radiological & Nuclear

• 79 Recruitment And Re-Enlistment

• 88 Transportation

• 89 Explosives And Ammunition

• 90 Logistics

• 91 Mechanical Maintenance

• 91 Ordnance

• 92 (43,57) Quartermaster Corps

• 94 (27,62,91) Electronic Maintenance

• 96 Intelligence

• 97 Counter/Human Intelligence

• 98 Communications Intelligence

• 999 Other

• Data unavailable

[USMC]

• 01 Personnel & Administration

• 02 Intelligence

• 03 Infantry

• 04 Logistics

• 05 Marine Air Ground Task Force (Magtf) Plans

• 06 Communications

• 08 Artillery

• 09 Training

• 11 Utilities

• 13 Engineer, Construction, Facilities & Equipment

• 18 Tank & Assault Amphibious Vehicle

• 21 Ground Ordnance Maintenance

• 23 Ammunition & Explosive Ordnance Disposal

• 26 Signals Intelligence/Ground Electronic Warfare

• 27 Linguist

• 28 Data/Communications Maintenance

• 30 Supply Administration & Operations

• 31 Distribution Management

• 33 Food Service

• 34 Financial Management

• 35 Motor Transport

• 41 Morale Welfare & Recreation

• 43 Public Affairs

• 44 Legal Services

• 46 Combat Camera

• 48 Recruiting And Retention Specialist

• 55 Music

• 57 Chemical, Biological, Radiological & Nuclear(Cbrn) Defense

• 58 Military Police & Corrections

• 59 Electronics Maintenance

• 60/61/62 Aircraft Maintenance

• 63/64 Avionics

• 65 Aviation Ordnance

• 66 Aviation Logistics

• 68 Meteorological & Oceanographic (Metoc)

• 70 Airfield Services

• 72 Air Control/Airsupport/Anti-Air Warfare Traffic Control

• 73 Navigation Officer/Enlisted Flight Crews

• 75 Pilots/Navel Flight Officers

[USN] {FREE TEXT}

18 Duty job at time of event (MOS, SSI, DAFSC, or other military job code)

[USAF]

• 1A0X1 In-Flight Refueling

• 1A1X1 Flight Engineer

• 1A2X1 Loadmaster

• 1A3X1 Airborne Communications Systems

• 1A4X1 Airborne Battle Management

• 1A5X1 Airborne Missions Systems

• 1C0X1 Airfield Management

• 1C0X2 Operations Resource Management

• 1C1X1 Air Traffic Control

• 1C2X1 Combat Control

• 1C3X1 Command Post

• 1C4X1 Tactical Air Command and Control

• 1C5X1 Aerospace Control and Warning Systems

• 1C6X1 Space Systems Operations

• 1N0X1 Intelligence Applications

• 1N1X1 Imagery Analysis

• 1N2X1 Signals Intelligence Production

• 1N3X1 Germanic Cryptologic Linguist

• 1N3X2 Romance Cryptologic Linguist

• 1N3X3 Slavic Cryptologic Linguist

• 1N3X4 Far East Cryptologic Linguist

• 1N3X5 Mid-East Cryptologic Linguist

• 1N4X1 Signals Intelligence Analysis

• 1N5X1 Electronic Signals Intelligence Exploitation

• 1N6X1 Electronic System Security Assessment

• 1S0X1 Safety

• 1T0X1 Survival, Evasion, Resistance, and Escape Training

• 1T1X1 Aircrew Life Support

• 1T2X1 Pararescue

• 1W0X1 Weather

• 2A0X1 Avionics Test Station and Components

• 2A1X1 Avionics Sensors Maintenance

• 2A1X2 Avionics Guidance & Control Systems

• 2A1X3 Communication & Navigation Systems

• 2A1X4 Airborne Surveillance Radar Systems

• 2A1X7 Electronic Warfare Systems

• 2A3X1 F-15/F-111 Avionics Systems

• 2A3X2 F-16, F-117, CV-22 Avionic Systems

• 2A3X3 Tactical Aircraft Maintenance

• 2A4X1 Aircraft Guidance & Control

• 2A4X2 Aircraft Communication & Navigation Systems

• 2A5X1 Aerospace Maintenance

• 2A5X2 Helicopter Maintenance

• 2A5X3 Bomber Avionics Systems

• 2A6X1 Aerospace Propulsion

• 2A6X2 Aerospace Ground Equipment

• 2A6X3 Aircrew Egress Systems

• 2A6X4 Aircraft Fuel Systems

• 2A6X5 Aircraft Hydraulic Systems

• 2A6X6 Aircraft Electrical and Environmental Systems

• 2A7X1 Aircraft Metals Technology

• 2A7X2 Nondestructive Inspection

• 2A7X3 Aircraft Structural Maintenance

• 2A7X4 Survival Equipment

• 2E0X1 Ground Radar Systems

• 2E1X1 Satellite and Wideband Communications Equip

• 2E1X2 Meteorological and Navigation Systems

• 2E1X3 Ground Radio Communications

• 2E1X4 Visual Imagery and Intrusion Detection Systems

• 2E2X1 Electronic Computer and Switching Systems

• 2E3X1 Secure Communication Systems

• 2E4X1 Space Systems

• 2E6X1 Communications Antenna Systems

• 2E6X2 Communication Cable Systems

• 2E6X3 Telephone Systems

• 2E8X1 Instrumentation and Telemetry

• 2F0X1 Fuels

• 2G0X1 Logistics Plans

• 2M0X1 Missile and Space Systems Elect Maintenance

• 2M0X2 Missile and Space Systems Maintenance

• 2M0X3 Missile and Space Facilities

• 2P0X1 Precision Measurement Equipment Laboratory

• 2R0X1 Maintenance Data Systems Analyst

• 2R1X1 Maintenance Scheduling

• 2S0X1 Supply Management

• 2S0X2 Supply Systems Analyst

• 2T0X1 Traffic Management

• 2T1X1 Vehicle Operations

• 2T2X1 Air Transportation

• 2T3X1 Special Purpose Vehicle and Equipment Maint

• 2T3X2 Special Vehicle Maintenance

• 2T3X4 General Purpose Vehicle Mechanic

• 2T3X5 Vehicle Body Maintenance

• 2T3X7 Vehicle Maintenance Control & Analysis

• 2W0X1 Munitions Systems

• 2W1X1 Aircraft Armament Systems

• 2W2X1 Nuclear Weapons

• 3A0X1 Information Management

• 3C0X1 Communication-Computer Systems Operations

• 3C0X2 Comm-Computer Systems Programming

• 3C1X1 Radio Communications Systems

• 3C1X2 Electromagnetic Spectrum Management

• 3C2X1 Communication-Computer Systems Control

• 3C3X1 Comm-Comp Sys Planning & Implementation

• 3E0X1 Electrical

• 3E0X2 Electrical Power Production

• 3E1X1 Heating, Ventilation, AC, & Refrigeration

• 3E2X1 Pavement and Construction Equipment

• 3E3X1 Structural

• 3E4X1 Utilities Systems

• 3E4X2 Liquid Fuel Systems Maintenance

• 3E4X3 Environmental

• 3E5X1 Engineering

• 3E6X1 Operations Management

• 3E7X1 Fire Protection

• 3E8X1 Explosive Ordnance Disposal

• 3E9X1 Readiness

• 3H0X1 Historian

• 3M0X1 Services

• 3N0X1 Public Affairs

• 3N0X2 Radio and Television Broadcasting

• 3N1X1 Regional Band

• 3N2X1 Premier Band

• 3P0X1 Security Forces

• 3S0X1 Personnel

• 3S0X2 Personnel Systems Management (PSM)

• 3S1X1 Military Equal Opportunity

• 3S2X1 Education and Training

• 3U0X1 Manpower and Quality Management

• 3V0X1 Visual Information

• 3V0X2 Still Photographic

• 3V0X3 Visual Information Production-Documentation

• 4A0X1 Health Services Management

• 4A1X1 Medical Materiel

• 4A2X1 Biomedical Equipment

• 4B0X1 Bioenvironmental Engineering

• 4C0X1 Mental Health Service

• 4D0X1 Diet Therapy

• 4E0X1 Public Health

• 4F0X1 Aeromedical

• 4H0X1 Cardiopulmonary Laboratory

• 4J0X1 Occupational Therapy

• 4J0X2 Physical Therapy

• 4M0X1 Aerospace Physiology

• 4N0X1 Medical Service

• 4N1X1 Surgical Service

• 4P0X1 Pharmacy

• 4R0X1 Diagnostic Imaging

• 4T0X1 Medical Laboratory

• 4T0X2 Histopathology

• 4T0X3 Cytotechnology

• 4U0X1 Orthotic

• 4V0X1 Optometry

• 4Y0X1 Dental Assistant

• 4Y0X2 Dental Laboratory

• 5J0X1 Paralegal

• 5R0X1 Chaplain Service Support

• 6C0X1 Contracting

• 6F0X1 Financial Management & Comptroller

• 7S0X1 Special Investigations

• 10C0 Operations Commander

• 11BX Bomber Pilot

• 11EX Test Pilot

• 11FX Fighter Pilot

• 11GX Generalist Pilot

• 11HX Helicopter Pilot

• 11KX Trainer Pilot

• 11MX Mobility Pilot

• 11RX Recce/Surv/Elect Warfare Pilot

• 11SX Special Operations Pilot

• 11UX Remotely Operated Aircraft

• 12BX Bomber Navigator

• 12EX Test Navigator

• 12FX Fighter Navigator

• 12GX Generalist Navigator

• 12KX Trainer Navigator

• 12MX Mobility Navigator

• 12RX Recce/Surv/Elect Warfare Navigator

• 12SX Special Operations Navigator

• 12UX Remotely Operated Aircraft

• 13AX Astronaut

• 13BX Air Battle Manager

• 13DX Control and Recovery

• 13MX Airfield Operation

• 13SX Space & Missile

• 14NX Intelligence

• 15WX Weather

• 16FX Foreign Area

• 16GX Air Force Operations Staff Officer

• 16PX Intl Politico-Military Affairs

• 16RX Planning & Programming

• 20C0 Logistics Commander

• 21AX Aircraft Maintenance

• 21BX Maintenance

• 21MX Munitions and Missile Maintenance

• 21RX Logistics Readiness

• 30C0 Support Commander

• 31PX Security Forces

• 32EX Civil Engineer

• 33C0 Communications Commander

• 33SX Communications and Information

• 34MX Services

• 35BX Band

• 35PX Public Affairs

• 36MX Mission Support

• 36PX Personnel

• 38MX Manpower

• 40C0 Medical Commander

• 41AX Health Services Administrator

• 42BX Physical Therapist

• 42EX Optometrist

• 42FX Podiatrist

• 42GX Physician Assistant

• 42NX Audiology/Speech Pathologist

• 42PX Clinical Psychologist

• 42SX Clinical Social Worker

• 42TX Occupational Therapist

• 43AX Aerospace Physiologist

• 43BX Biomedical Scientist

• 43DX Dietitian

• 43EX Bioenvironmental Engineer

• 43HX Public Health

• 43MX Medical Entomologist

• 43PX Pharmacist

• 43TX Biomedical Laboratory

• 43VX Veterinary Clinician

• 43YX Health Physicist

• 44AX Chief, Hospital/Clinic Services

• 44BX Preventive Medicine

• 44DX Pathologist

• 44EX Emergency Services Physician

• 44FX Family Physician

• 44GX General Practice Physician

• 44HX Nuclear Medicine Physician

• 44JX Clinical Geneticist

• 44KX Pediatrician

• 44MX Internist

• 44NX Neurologist

• 44PX Psychiatrist

• 44RX Diagnostic Radiologist

• 44SX Dermatologist

• 44TX Radiotherapist

• 44UX Occupational Medicine

• 44YX Critical Care Medicine

• 44ZX Allergist

• 45AX Anesthesiologist

• 45BX Orthopedic Surgeon

• 45EX Ophthalmologist

• 45GX OB/GYN

• 45NX Otorhinolaryngologist

• 45PX Physical Medicine Physician

• 45SX Surgeon

• 45UX Urologist

• 46AX Nurse Administrator

• 46FX Flight Nurse

• 46GX Nurse-Midwife

• 46MX Nurse Anesthetist

• 46NX Clinical Nurse

• 46PX Mental Health Nurse

• 46SX Operating Room Nurse

• 47BX Orthodontist

• 47DX Oral and Maxillofacial Pathologist

• 47EX Endodontist

• 47GX Dentist

• 47HX Periodontist

• 47KX Pediatric Dentist

• 47PX Prosthodontist

• 47SX Oral Surgeon

• 48AX Aerospace Medicine Specialist

• 48GX General Medical Officer (GMO)

• 48RX Residency Trained Flight Surgeon

• 48VX Pilot-Physician

• 51JX Judge Advocate

• 52RX Chaplain

• Other [Specify: {FREE TEXT}]

• Data unavailable

[USA]

• 9 Officer Candidates

• 11 Infantry

• 12 Engineer

• 13 Field Artillery

• 14 Air Defense Artillery

• 15 Aviation

• 18 Special Forces

• 19 Armor

• 21 (62b) Corps Of Engineers

• 24 Telecommunications Systems Engineering

• 25 Communications And Information Systems Operation

• 25 Signal Corps

• 27 Paralegal

• 29 Electronic Warfare

• 30 Information Operations

• 31 Military Police

• 33 Electronic Warfare

• 34 Strategic Intelligence

• 35 Military Intelligence

• 36 Financial Management

• 37 Psychological Operations

• 38 Civil Affairs (Aa And Usar)

• 40 Space Operations

• 44 Finance

• 42 Adjutant General Corps

• 45 Armament Maintenance

• 46 Public Affairs

• 47 Usma Stabilized Facility

• 48 Foreign Area Officer

• 49 Operations Research/Systems Analysis

• 50 Force Management

• 51 Acquisition, Logistics And Technology

• 71 Laboratory Sciences

• 72 Preventive Medicine Sciences

• 73 Behavioral Sciences

• 74 Chemical, Biological Radiological & Nuclear

• 79 Recruitment And Re-Enlistment

• 88 Transportation

• 89 Explosives And Ammunition

• 90 Logistics

• 91 Mechanical Maintenance

• 91 Ordnance

• 92 (43,57) Quartermaster Corps

• 94 (27,62,91) Electronic Maintenance

• 96 Intelligence

• 97 Counter/Human Intelligence

• 98 Communications Intelligence

• 999 Other

• Data unavailable

[USMC]

• 01 Personnel & Administration

• 02 Intelligence

• 03 Infantry

• 04 Logistics

• 05 Marine Air Ground Task Force (Magtf) Plans

• 06 Communications

• 08 Artillery

• 09 Training

• 11 Utilities

• 13 Engineer, Construction, Facilities & Equipment

• 18 Tank & Assault Amphibious Vehicle

• 21 Ground Ordnance Maintenance

• 23 Ammunition & Explosive Ordnance Disposal

• 26 Signals Intelligence/Ground Electronic Warfare

• 27 Linguist

• 28 Data/Communications Maintenance

• 30 Supply Administration & Operations

• 31 Distribution Management

• 33 Food Service

• 34 Financial Management

• 35 Motor Transport

• 41 Morale Welfare & Recreation

• 43 Public Affairs

• 44 Legal Services

• 46 Combat Camera

• 48 Recruiting And Retention Specialist

• 55 Music

• 57 Chemical, Biological, Radiological & Nuclear(Cbrn) Defense

• 58 Military Police & Corrections

• 59 Electronics Maintenance

• 60/61/62 Aircraft Maintenance

• 63/64 Avionics

• 65 Aviation Ordnance

• 66 Aviation Logistics

• 68 Meteorological & Oceanographic (Metoc)

• 70 Airfield Services

• 72 Air Control/Airsupport/Anti-Air Warfare Traffic Control

• 73 Navigation Officer/Enlisted Flight Crews

• 75 Pilots/Navel Flight Officers

[USN] {FREE TEXT}

19 Personnel reliability program (PRP) at time of event

• Yes

• No

• Data unavailable

20 For the job held at the time of the event, did the patient/decedent

Work more than 50 hours per week?

• Yes

• No

• Data unavailable

Have stress associated with work environments due to limited resources (e.g., personnel)?

• Yes

• No

• Data unavailable

Have job duties or work environments that were unpredictable?

• Yes

• No

• Data unavailable

Have an increase in workload, production, or quotas (within 30 days of the event)?

• Yes

• No

• Data unavailable

Have a job that caused him or her to have less than 8 hours of sleep in the 72 hours prior to the event?

• Yes

• No

• Data unavailable

21 [IF 16 = RESERVE OR NATIONAL GUARD] Duty status at time of event (check all that apply)

• Active Guard Reserve (AGR) or Full Time Support (FTS)

• Mobilized for contingency operation (OIF, OEF, etc.)

• ADOS (less than 29 or over 29 days)

• Drill, annual training, active duty for training status

• Not in a duty status

22 Pay grade

• E1

• E2

• E3

• E4

• E5

• E6

• E7

• E8

• E9

• W1

• W2

• W3

• W4

• W5

• O1

• O2

• O3

• O4

• O5

• O6

• O7

• O8

• O9

• O10

• Cadet/Midshipman

23 Permanent duty station/command location

Country/Region

• United States

State

• Alabama

[USAF] Base:

• Maxwell-Gunter

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Rucker

• Redstone Arsenal

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Alaska

[USAF] Base:

• Eielson AFB

• Elmendorf AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• USAG-Richardson

• USAG-Wainwright

• USAG-Fort Greely

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Arizona

[USAF] Base:

• Davis-Monthan AFB

• Luke AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Huachuca

• Yuma Proving Ground

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Arkansas

[USAF] Base:

• Little Rock AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Pine Bluff Arsenal

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• California

[USAF] Base:

• Beale AFB

• Edwards AFB

• Los Angeles AFB

• Travis AFB

• Vandenberg

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Irwin

• Presidio of Monterrey

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Colorado

[USAF] Base:

• Buckley AFB

• Cheyenne Mountain AFS

• Peterson AFB

• Schriever AFB

• USAFA

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Carson

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Connecticut

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Delaware

[USAF] Base:

• Dover AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• District of Columbia

[USAF] Base:

• Bolling AFB

• Pentagon

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Walter Reed Army Medical Center

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Florida

[USAF] Base:

• Eglin AFB

• Hurlburt Field

• MacDill AFB

• Patrick AFB

• Tyndall AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• USAG, Miami

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Georgia

[USAF] Base:

• Moody AFB

• Robins AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Benning

• Fort Gordon

• Fort McPherson

• Fort Stewart

• Hunter Army Airfield

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Hawaii

[USAF] Base:

• Hickam AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• USAG, Hawaii

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Idaho

[USAF] Base:

• Mountain Home AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Illinois

[USAF] Base:

• Scott AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Rock Island Arsenal

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Indiana

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Iowa

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Kansas

[USAF] Base:

• McConnell AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Leavenworth

• Fort Riley

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Kentucky

[USAF] Base: {FREE TEXT}

[USA] Installation:

• Fort Campbell

• Fort Knox

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Louisiana

[USAF] Base:

• Barksdale AFB

• Hammond Com

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Polk

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Maine

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Maryland

[USAF] Base:

• Andrews AFB

• Fort Meade

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Aberdeen Proving Ground

• Fort Detrick

• Fort Meade

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Massachusetts

[USAF] Base:

• Hanscom AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Devens

• USAG-Natick

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Michigan

[USAF] Base: {FREE TEXT}

[USA] Installation:

• Detroit Arsenal

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Minnesota

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Mississippi

[USAF] Base:

• Columbus AFB

• Keesler AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Missouri

[USAF] Base:

• Whiteman AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Leonard Wood

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Montana

[USAF] Base:

• Malmstrom AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Nebraska

[USAF] Base:

• Offutt AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Nevada

[USAF] Base:

• Creech AFB

• Nellis AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• New Hampshire

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• New Jersey

[USAF] Base:

• McGuire/Dix/Lakehurst

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Dix

• Fort Monmouth

• Picatinny Arsenal

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• New Mexico

[USAF] Base:

• Cannon AFB

• Holloman AFB

• Kirtland AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• White Sands Missile Range

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• New York

[USAF] Base: {FREE TEXT}

[USA] Installation:

• Fort Drum

• Fort Hamilton

• West Point

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• North Carolina

[USAF] Base:

• Pope AFB

• Seymour-Johnson AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Bragg

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• North Dakota

[USAF] Base:

• Cavalier AFS

• Grand Forks AFB

• Minot AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Ohio

[USAF] Base:

• Wright-Patterson AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• USAG, Miami

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Oklahoma

[USAF] Base:

• Altus AFB

• Tinker AFB

• Vance AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Sill

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Oregon

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Pennsylvania

[USAF] Base: {FREE TEXT}

[USA] Installation:

• Carlisle Barracks

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Rhode Island

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• South Carolina

[USAF] Base:

• Charleston AFB

• Shaw AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Jackson

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• South Dakota

[USAF] Base:

• Ellsworth AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Tennessee

[USAF] Base:

• Arnold AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Texas

[USAF] Base:

• Brooks City AFB

• Dyess AFB

• Goodfellow AFB

• Lackland AFB

• Laughlin AFB

• Randolf AFB

• Sheppard AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Bliss

• Fort Hood

• Fort Sam Houston

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Utah

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Vermont

[USAF] Base:

• Hill AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Virginia

[USAF] Base:

• Langley AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort AP Hill

• Fort Belvoir

• Fort Eustis

• Fort Lee

• Fort Monroe

• Fort Myer

• Fort Story

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Washington

[USAF] Base:

• McChord AFB

• Fairchild AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort Lewis

• Yakima Training Center

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• West Virginia

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Wisconsin

[USAF] Base:

• General Mitchell ARS

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Fort McCoy

• Other [Specify: {FREE TEXT}]

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Wyoming

[USAF] Base:

• FE Warren AFB

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Installation: {FREE TEXT}

[USN] Installation: {FREE TEXT}

• Iraq

[USAF] Base:

• Ali Air Base

• Kirkuk Regional Air Base

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• Afghanistan

[USAF] Base:

• Bagram Air Field

• Other [Specify: {FREE TEXT}]

[USA] Installation: {FREE TEXT}

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• Kuwait

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• Korea

[USAF] Base:

• Kunsan AB

• Osan AB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• USAG Casey

• USAG Daegu

• USAG Humphreys

• USAG Red Cloud

• USAG Yongsan

• Other [Specify: {FREE TEXT})

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• Belgium

[USAF] Base:

• Brussels

• Chievres

• Flobecq

• Florennes

• Kester

• Klein Brogel

• SHAPE

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• USAG Benelux

• USAG Brussels

• Other [Specify: {FREE TEXT})

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• Germany

[USAF] Base:

• Bann

• Baumholder

• Berlin

• Bitburg

• Buechel

• Einsiedlerhof

• Frankfurt

• Friedberg

• Geilenkerchen AB

• Giebelstadt

• Grafenwohr

• Hanau

• Illesheim

• Kalkar

• Kapaun

• Katterbach

• Landstuhl

• Pruem

• Ramstein AB

• Sembach

• Siegenberg

• Spangdahlem

• Vilseck

• Wurzburg

• USAG Heidelberg

• USAG Hohenfels

• USAG Kaiserslautern

• USAG Manheim

• USAG Schweinfurt

• USAG Stuttgart

• USAG Wiesbaden

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• USAG Ansbach

• USAG Baden-Wurttemberg

• USAG Bamberg

• USAG Garmisch

• USAG Grafenwoehr

• USAG Heidelberg

• USAG Hohenfels

• USAG Kaiserslautern

• USAG Manheim

• USAG Schweinfurt

• USAG Stuttgart

• USAG Wiesbaden

• Other [Specify: {FREE TEXT})

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• Kosovo

[USAF] Base: {FREE TEXT}

[USA] Installation: {FREE TEXT}

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• United Kingdom

[USAF] Base:

• London Heathrow

• RAF Alconbury

• RAF Croughton

• RAF Daws Hill

• RAF Fairford

• RAF Feltwell

• RAF Lakenheath

• RAF Menwith Hill

• RAF Mildenhall

• RAF Molesworth

• RAF Upwood

• RAF Welford

• Waterbeach

  • Other [Specify: {FREE TEXT}]

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• Other Europe

[USAF] Base:

• Amsterdam, Netherlands

• Athens, Greece

• Brunssum, Netherlands

• Camp Darby-Liverno, Italy

• Camp Ederle-Vincenza, Italy

• Coopenhagen, Denmark

• Gaeta, Italy

• Ghedi, Italy

• Karup, Denmark

• Lajes Field (Azores), Portugal

• Lisbon, Portugal

• Madrid, Spain

• Moron AB, Spain

• Napels, Italy

• Paris, France

• Stavenger, Norway

• The Hague, Netherlands

• Volkel, Netherlands

• Other [Specify: {FREE TEXT}]

. [USA] Installation:

• USAG Livorno, Italy

• USAG Vicenza, Italy

• USAG Schinnen, Netherlands

• Other [Specify: {FREE TEXT})

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• North America

[USAF] Base:

• North Bay, Canada

• Thule AB, Greenland

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• Ft. Buchanan, Puerto Rico

• Other [Specify: {FREE TEXT}]

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• Japan

[USAF] Base:

• Kadena AB

• Misawa AB

• Yokota AB

• Other [Specify: {FREE TEXT}]

[USA] Installation:

• USAG Japan

• Other [Specify: {FREE TEXT}]

[USMC] Marine Corps Installation: {FREE TEXT}

[USN] Navy Installation: {FREE TEXT}

• Other

[USAF] Please specify: {FREE TEXT}

Base: {FREE TEXT}

[USA] Please specify: {FREE TEXT}

Army Installation: {FREE TEXT}

[USMC] Please specify: {FREE TEXT}

Marine Corps Installation: {FREE TEXT}

[USN] Please specify: {FREE TEXT}

Navy Installation: {FREE TEXT}

• Data unavailable

24 Permanent duty assignment

[USAF]

MAJCOM:

• ACC

• AETC

• AFDW

• AF ISR Agency

• AFMC

• AFSOC

• AFSPC

• AMC

• PACAF

• USAFA

• USAFE

• HQ USAF

• AFRC

• ANG

• AFGSC

• Other [Specify: {FREE TEXT}]

[USA]

Division:

• 1st Armored

• 1st Cavalry

• 2nd Infantry

• 3rd Infantry

• 4th Infantry

• 10th Mountain

• 25th Infantry

• 82nd Airborne

• 101st Airborne

• 7th Infantry

• 24th Infantry

• 28th Infantry

• 29th Infantry

• 34th Infantry

• 35th Infantry

• 38th Infantry

• 40th Infantry

• 42nd Infantry

• 49th Infantry

• 75th Infantry

• 78th Infantry (Training Support)

• 80th Division

• 84th Division

• 85th Division

• 87th Division

• 91st Division

• 95th Division

• 98th Division

• 100th Division

• 104th Division

• 108th Division

• TRADOC

• USARSO

• USASMDC

• AMC

• USARPAC

• ARSTRAT

• USARCENT

• USARAF

• EUSA

• USAREUR

• USASOC

• USMA

• USARNORTH

• SDDC

• IMCOM

• NETCOM

• INSCOM

• ATEC

• USACIDC

• Other [Specify: {FREE TEXT}]

Brigade: {FREE TEXT}

Battalion: {FREE TEXT}

Company: {FREE TEXT}

[USMC]

Marine Corps Operating Force:

• MARFORCOM

• MARFORPAC

• MARFORRES

• HQMC

• Other [Specify: {FREE TEXT}]

MAJCOM

• HQMC

• MARFORRES

• I MEF

• II MEF

• III MEF

• Other [Specify: {FREE TEXT}]

MSC

• 1st MARDIV

• 3D MAW

• 1st MLG

• 1st MEB

• 11th MEU

• 13th MEU

• 15th MEU

• I MHG

• 4th MARDIV

• 4th MAW

• 4th MLG

• MARINE LOGISTICS

• MOBCOMM

• 2D MARDIV

• 2D MAW

• 2D MLG

• 2D MEB

• 22D MEU

• 24th MEU

• 26th MEU

• Chem/Bio Incident Resp Force

• MC Security Force Reg

• Other [Specify: {FREE TEXT}]

Regiment/Battalion/Company: {FREE TEXT}

[USN]

• Name of unit: {FREE TEXT}

• MSC (Echelon 2): {FREE TEXT}

• MAJCOM: {FREE TEXT}

• Marine Corps Operating Force: {FREE TEXT}

25 UIC or other unit identification: {FREE TEXT}

26 Date of entry into the military: {MM/DD/YYYY}

Date of rank: {MM/DD/YYYY}

27 Length of time in unit: {00-49} years; {00-12} months

28 [USA ONLY] In a warrior transition unit (WTU)?

• Yes

• No

• Data unavailable

[IF YES] Please select the WTU

• FT Wainwright, AK

• FT Richardson, AK

• CBWTU, AL

• CBWTU, AR

• FT Huachuca, AZ

• Balboa, CA

• FT Irwin, CA

• FT Carson, CO

• CBWTU, FL

• FT Benning, GA

• FT Gordon, GA

• FT Stewart, GA

• Schofield Barracks, HI

• CBWTU, IL

• FT Riley, KS

• FT Campbell, KY

• FT Knox, KY

• FT Polk, LA

• CBWTU, MA

• FT Meade, MD

• FT Landlord Wood, MO

• FT Bragg, NC

• FT Dix, NJ

• FT Drum, NY

• West Point, NY

• FT Sill, OK

• CBWTU, Puerto Rico

• FT Jackson, SC

• FT Hood, TX

• FT Sam Houston, TX

• FT Bliss, TX

• CBWTU, UT

• CBWTU, VA

• FT Belvoir, VA FT Eustis, VA

• Joint Base Lewis McChord, WA

• Walter Reed Army Medical Center

29 Geographic location of event:

Country:

• United States

State:

• Alabama

• Alaska

• Arizona

• Arkansas

• California

• Colorado

• Connecticut

• Delaware

• District of Columbia

• Florida

• Georgia

• Hawaii

• Idaho

• Illinois

• Indiana

• Iowa

• Kansas

• Kentucky

• Louisiana

• Maine

• Maryland

• Massachusetts

• Michigan

• Minnesota

• Mississippi

• Missouri

• Montana

• Nebraska

• Nevada

• New Hampshire

• New Jersey

• New Mexico

• New York

• North Carolina

• North Dakota

• Ohio

• Oklahoma

• Oregon

• Pennsylvania

• Rhode Island

• South Carolina

• South Dakota

• Tennessee

• Texas

• Utah

• Vermont

• Virginia

• Washington

• West Virginia

• Wisconsin

• Wyoming

• Iraq

• Afghanistan

• Kuwait

• Korea

• Kosovo

• Other Europe

• North America

• Central or South America

• Belgium

• Germany

• United Kingdom

• Other [Specify: {FREE TEXT}]

• Data unavailable

City/Post/Camp/Base: {FREE TEXT}

30 Event setting:

• Barracks

• Residence (own)

• Residence of friend or family

• Work/jobsite

• Automobile (away from residence)

• Inpatient medical facility

• Other [Specify: {FREE TEXT}]

31 [IF NOT SUICIDE] Action taken as a consequence of the current event:

• Hospitalization (inpatient)

[IF HOSPITALZED]

Start date of hospitalization: {MM/DD/YYYY}

• Check box if unknown

End date of hospitalization: {MM/DD/YYYY}

• Check box if unknown

• Check if patient is still in the inpatient facility

Name of hospital the patient was admitted at: {FREE TEXT}

• Outpatient mental health evaluation/treatment

• Evacuation

• Other [Specify: {FREE TEXT}]

32 Primary method used/considered:

• Drugs

• Alcohol

• Gas, vapor poisoning by vehicle exhaust

• Gas, vapor poisoning by utility (or other) gas

• Solvents, pesticides and other agricultural chemicals

• Hanging/Asphyxiation

• Drowning

• Firearm/gun, military issue or duty weapon

• Firearm/gun, other than military issue

• Fire, steam, etc.

• Sharp or blunt object

• Jumping from high place

• Struck by moving object

• Crashing a motor vehicle

• Other [Specify: {FREE TEXT}]

• Data unavailable

33 During the event, was alcohol used?

• Yes

• No

• Data unavailable

34 During the event, were drugs used?

• Yes

[IF YES] What types of drugs were used?

Drugs (illicit/illegal):

• Overdose

• Used, no overdose

• Were not used

Prescription medications:

• Overdose

• Used, no overdose

• Were not used

Non-prescription medications

• Overdose

• Used, no overdose

• Were not used

• No

• Data unavailable

35 Is there evidence that the patient/decedent intended to die?

• Yes

[IF YES] Please describe the evidence of intent to die. {FREE TEXT}

• No

• Cannot determine

36 Were there self-inflicted injuries (including poisoning)?

• Yes

• No

• Cannot determine

37 Is there evidence the event involved death-risk gambling?

• Yes

• No

• Data unavailable

38 Is there evidence the event was planned and/or premeditated?

• Yes

• No

• Data unavailable

39 Was the event performed under circumstances where it would likely be observed and intervened on by others?

• Yes

• No

• Data unavailable

40 Was a suicide note left?

• Yes

• No

• Data unavailable

41 Prior to the event, did the patient/decedent communicate potential for self-harm, other than a suicide note?

• Yes

[IF YES] How?

• Written

• Verbal

• Text or other electronic messaging

• Other [Specify: {FREE TEXT}]

[IF YES] To whom?

• Supervisor

• Chaplain

• Mental health staff

• Friend

• Spouse or significant other

• Other [Specify: {FREE TEXT}]

• No

• Data unavailable

42 What was the patient’s/decedent’s primary motivation for performing this event?

• Emotion relief

• Interpersonal influence

• Feeling generation

• Avoidance/escape

• Individual reasons

• Hopelessness

• Depression

• Other psychiatric symptoms

• Impulsivity

• Other [Specify: {FREE TEXT}]

• Data unavailable

43 Duty environment/status at the time of the event (check all that apply).

• Garrison/Home port/Base

• Leave

• TDY/TAD

• AWOL (Absent Without Leave)

• Deployed

• Basic or Initial Entry Training/Advanced Individual Training

• Training (School, Course)

• Psychiatric hospitalization

• Medical Hold/Limited Duty/WTU

• In evacuation chain

• Under command observation

• Other [Specify: {FREE TEXT}]

44 Please describe the sequence of events leading up to the event and discovery/intervention. {FREE TEXT}

45 Prior to the event, was the patient/decedents seen by a medical treatment facility?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] Is the medical location military-run or civilian-run?

• Military treatment facility or clinic

• Civilian facility

• Data unavailable

• No

• Data unavailable

46 Prior to the event, was the patient/decedent seen by substance abuse services?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] Is the medical location military-run or civilian-run?

• Military treatment facility or clinic

• Civilian facility

• Data unavailable

• No

• Data unavailable

47 Prior to the event, was the patient/decedent seen by a family advocacy program?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] Is the medical location military-run or civilian-run?

• Military treatment facility or clinic

• Civilian facility

• Data unavailable

• No

• Data unavailable

48 Prior to the event, was the patient/decedent seen by outpatient behavioral health?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] Is the medical location military-run or civilian-run?

• Military treatment facility or clinic

• Civilian facility

• Data unavailable

• No

• Data unavailable

49 Prior to the event, was the patient/decedent seen by inpatient behavioral health?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] Is the medical location military-run or civilian-run?

• Military treatment facility or clinic

• Civilian facility

• Data unavailable

• No

• Data unavailable

50 Prior to the event, had the patient/decedent been diagnosed with any mood disorder?

• Yes

[IF YES] Bipolar disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Major depression

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Dysthymic disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] any other mood disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

• No

• Data unavailable

51 Prior to the event, had the patient/decedent been diagnosed with any anxiety disorder?

• Yes

[IF YES] PTSD

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] panic disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] generalized anxiety disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] acute stress disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] any other anxiety disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

• No

• Data unavailable

52 Prior to the event, had the patient/decedent been diagnosed with any sleep disorder?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] Sleep disorder details {FREE TEXT}

• No

• Data unavailable

53 Prior to the event, had the patient/decedent been diagnosed with any adjustment disorder?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

54 Prior to the event, had the patient/decedent been diagnosed with any personality disorder?

• Yes

[IF YES] Paranoid personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Schizoid personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Schizotypal personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Antisocial personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Borderline personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Histrionic personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Narcissistic personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Avoidant personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Dependent personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Obsessive compulsive personality disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Personality disorder NOS

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

• No

• Data unavailable

55 Prior to the event, had the patient/decedent been diagnosed with any psychotic disorder?

• Yes

[IF YES] Schizophrenia, catatonic type

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Schizophrenia, disorganized type

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Schizophrenia, paranoid type

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Schizophrenia, residual type

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Schizophrenia, undifferentiated type

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Schizophreniform disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Schizoaffective disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Delusional disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Brief psychotic disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Shared psychotic disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] psychotic disorder due to medical condition

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Substance-induced psychotic disorder

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Psychotic disorder NOS

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

• No

• Data unavailable

56 Prior to the event, had the patient/decedent been diagnosed with a traumatic brain injury?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

57 Prior to the event, had the patient/decedent been diagnosed with any other psychiatric disorder? {FREE TEXT}

58 Prior to the event, did the patient/decedent have a history of substance abuse?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] Please select all that apply:

• Alcohol dependence

• Alcohol abuse

• Drugs (illicit/illegal) dependence

• Drugs (illicit/illegal) abuse

• Inhalant dependence

• Inhalant abuse

• Prescription medication dependence

• Prescription medication abuse

• Non-prescription medication dependence

• Non-prescription medication abuse

• No

• Data unavailable

59 Did the patient/decedent have a history of tobacco use?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] Check one:

• Smoker

• Smokeless

• No

• Data unavailable

60 Prior to the event, had the patient/decedent taken psychotropic medications?

• Yes

[IF YES] Antidepressants

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Antianxiety medications

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Antimanics

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Anticonvulsants

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Antipsychotics

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Sleep medications

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[IF YES] Did the patient/decedent have active prescribed medications within 90 days of the event?

• Yes

• No

• Data unavailable

• No

• Data unavailable

61 Was the patient/decedent known to use pain medication at the time of the event?

• Yes

[IF YES] Was the patient/decedent known to be using opioids at the time of the event?

• Yes

• No

• Data unavailable

[IF YES] Select all that apply:

• Over the counter pain medication use

• Over the counter pain medication dependence

• Over the counter pain medication abuse

• Prescription pain medication use

• Prescription pain medication dependence

• Prescription pain medication abuse

• No

• Data unavailable

62 Please indicate whether the patient/decedent met the criteria of polypharmacy at the time of the event?

• Yes

• No

• Data unavailable

63 Did the patient/decedent have prior self-injurious events?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] How many prior events?

• One

• More than one

[IF YES] Was this event similar to prior events?

• Yes

• No

• Data unavailable

• No

• Data unavailable

64 Did the patient/decedent receive his/her required suicide prevention training?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

[IF YES] What training was received, and how was it delivered? {FREE TEXT}

• No

• Data unavailable

65 Are there other relevant detailed related to the patient’s/decedent’s behavioral health treatment history?

• Yes

[IF YES] Please elaborate on any other relevant details related to the patient/decedent’s behavioral health treatment history. {FREE TEXT}

• No

• Data unavailable

66 Prior to the event, was the patient/decedent the subject of courts martial proceedings?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

67 [USAF & USA Only] Prior to the event, was the patient/decedent the subject of Article 15 or civilian criminal proceedings?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

[USMC & USN Only] Prior to the event, was the patient/decedent the subject of non-judicial punishment or civilian criminal proceedings?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

68 Prior to the event, was the patient/decedent the subject of an ongoing inquiry or investigation for alleged misconduct?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

69 Prior to the event, was the patient/decedent the subject of administrative separation proceedings?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

70 Prior to the event, was the patient/decedent the subject of AWOL/UA?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

71 Prior to the event, was the patient/decedent the subject of a medical evaluation board?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

72 Prior to the event, was the patient/decedent the subject of civil legal problems?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

73 Prior to the event, was the patient/decedent the subject of non-selection of advanced school, promotion, or command?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

74 Were there other known life stressors or other circumstances affecting the patient/decedent prior to the event?

• Yes

[IF YES] Please elaborate on any other relevant details related to the patient’/decedent’s known life stressors or other circumstances affecting the patient/decedent prior to the event. {FREE TEXT}

• No

• Data unavailable

75 How many deployments?

• 0

• 1

[IF 1] Please specify current or most recent deployment first. What was deployment location 1?

• United States

• Iraq

• Afghanistan

• Kuwait

• Korea

• Kosovo

• Other Europe

• North America

• Central or South America

• Other [Specify: {FREE TEXT}]

[IF 1] Deployed with:

• Parent command

• Individually [With what command did they deploy? {FREE TEXT}]

[IF 1] Deployment 1 start date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 1] Deployment 1 end date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 1] Deployment 1 R&R start date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 1] Deployment 1 R&R end date: {MM/DD/YYYY}

• Actual

• Estimate

• 2

[IF 2] Please specify current or most recent deployment first. What was deployment location 1?

• United States

• Iraq

• Afghanistan

• Kuwait

• Korea

• Kosovo

• Other Europe

• North America

• Central or South America

• Other [Specify: {FREE TEXT}]

[IF 2] Deployed with:

• Parent command

• Individually [With what command did they deploy? {FREE TEXT}]

[IF 2] Deployment 1 start date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 2] Deployment 1 end date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 2] Deployment 1 R&R start date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 2] Deployment 1 R&R end date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 2] What was deployment location 2?

• United States

• Iraq

• Afghanistan

• Kuwait

• Korea

• Kosovo

• Other Europe

• North America

• Central or South America

• Other [Specify: {FREE TEXT}]

[IF 2] Deployed with:

• Parent command

• Individually [With what command did they deploy? {FREE TEXT}]

[IF 2] Deployment 2 start date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 2] Deployment 2 end date: {MM/DD/YYYY}

• Actual

• Estimate

• 3 or more

[IF 3 OR MORE] Please specify current or most recent deployment first. What was deployment location 1?

• United States

• Iraq

• Afghanistan

• Kuwait

• Korea

• Kosovo

• Other Europe

• North America

• Central or South America

• Other [Specify: {FREE TEXT}]

[IF 3 OR MORE] Deployed with:

• Parent command

• Individually [With what command did they deploy? {FREE TEXT}]

[IF 3 OR MORE] Deployment 1 start date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 3 OR MORE] Deployment 1 end date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 3 OR MORE] Deployment 1 R&R start date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 3 OR MORE] Deployment 1 R&R end date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 3 OR MORE] What was deployment location 2?

• United States

• Iraq

• Afghanistan

• Kuwait

• Korea

• Kosovo

• Other Europe

• North America

• Central or South America

• Other [Specify: {FREE TEXT}]

[IF 3 OR MORE] Deployed with:

• Parent command

• Individually [With what command did they deploy? {FREE TEXT}]

[IF 3 OR MORE] Deployment 2 start date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 3 OR MORE] Deployment 2 end date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 3 OR MORE] What was deployment location 3?

• United States

• Iraq

• Afghanistan

• Kuwait

• Korea

• Kosovo

• Other Europe

• North America

• Central or South America

• Other [Specify: {FREE TEXT}]

[IF 3 OR MORE] Deployed with:

• Parent command

• Individually [With what command did they deploy? {FREE TEXT}]

[IF 3 OR MORE] Deployment 3 start date: {MM/DD/YYYY}

• Actual

• Estimate

[IF 3 OR MORE] Deployment 3 end date: {MM/DD/YYYY}

• Actual

• Estimate

76 Was a waiver to deploy required and/or obtained for OIF/OEF?

• Yes

• No

• Data unavailable

77 Did the patient/decedent experience direct combat operations?

• Yes

[IF YES] How long prior to the event?

• Deployment 1

• Deployment 2

• Deployment 3

[IF YES] Did the patient/decedent and his/her unit engage in battle resulting in casualties/wounded?

• Deployment 1

• Deployment 2

• Deployment 3

[IF YES] Did the patient/decedent become wounded or injured in combat?

• Deployment 1

• Deployment 2

• Deployment 3

[IF YES] Did the patient/decedent personally witness a unit member, ally, enemy, or civilian being seriously wounded or killed?

• Deployment 1

• Deployment 2

• Deployment 3

[IF YES] Did the patient/decedent kill others in combat?

• Deployment 1

• Deployment 2

• Deployment 3

• No

• Data unavailable

78 Did the patient/decedent have orders to deploy?

• Yes

• No

• Not applicable

• Data unavailable

79 Was the event related to a deployment?

• Yes

[IF YES] What type of deployment?

• Anticipated deployment

• Current deployment

• Prior deployment

• No

• Data unavailable

80 Is there any additional relevant military history including additional relevant deployment history?

• Yes

[IF YES] Please describe any additional relevant military history including additional relevant deployment history. {FREE TEXT}

• No

• Data unavailable

81 Prior to the event, was the patient/decedent an alleged or confirmed victim of physical abuse or assault?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

82 Prior to the event, was the patient/decedent an alleged or confirmed victim of sexual abuse or assault?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

83 Prior to the event, was the patient/decedent an alleged or confirmed victim of emotional abuse or assault?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

84 Prior to the event, was the patient/decedent an alleged or confirmed victim of sexual harassment?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

85 Prior to the event, was the patient/decedent an alleged or confirmed perpetrator of physical abuse or assault?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

86 Prior to the event, was the patient/decedent an alleged or confirmed perpetrator of sexual abuse or assault?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

87 Prior to the event, was the patient/decedent an alleged or confirmed perpetrator of emotional abuse or assault?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

88 Prior to the event, was the patient/decedent an alleged or confirmed perpetrator of sexual harassment?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

89 Are there any known childhood developmental history issues that may have contributed to the event?

• Yes

[IF YES] Please describe any known childhood developmental history issues that may have contributed to the event. {FREE TEXT}

• No

• Data unavailable

90 Prior to the event, was there evidence of a failed or failing spousal or intimate partner relationship?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

91 Prior to the event, was there evidence of a failed or failing other relationship?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

92 Prior to the event, was there evidence of a spousal suicide?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

93 Prior to the event, was there evidence of a family suicide?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

94 Prior to the event, was there evidence a suicide by a friend?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

95 Prior to the event, was there evidence of a death of a spouse or family member, other than suicide?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

96 Prior to the event, was there evidence of a death of a friend?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

97 Prior to the event, was there evidence of a physical health problem?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

98 Prior to the event, was there evidence of a chronic spousal or family severe illness?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

99 Prior to the event, was there evidence of excessive debt or bankruptcy?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

100 Prior to the event, was there evidence of job problems?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

101 Prior to the event, was there evidence of supervisor or coworkers issues/problems?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

102 Prior to the event, was there evidence of a poor work performance review or evaluation?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

103 Prior to the event, was there evidence of unit or workplace hazing?

• Yes

[IF YES] How long prior to the event?

• Within 30 days

• Within 3 months

• Within 1 year

• Over 1 year ago

• No

• Data unavailable

104 Did the patient/decedent have a family history of mental illness?

• Yes

• No

• Data unavailable

105 Was there a gun in the home or immediate environment?

• Yes

• No

• Data unavailable

106 Are there any additional details related to these factors?

• Yes

[IF YES] Please describe or elaborate on any additional details related to the factors (items 92-105). {FREE TEXT}

• No

• Data unavailable

107 Provide a brief explanation as to why this patient/decedent engaged in suicidal behavior. Include information that may help prevent future suicidal behavior for other service members. {FREE TEXT}

108 Location where this DoDSER was completed:

• Same as geographic event location

• Other location

[IF OTHER LOCATION] Country/Region

• United States

[IF UNITED STATES] State

• Alabama

• Alaska

• Arizona

• Arkansas

• California

• Colorado

• Connecticut

• Delaware

• District of Columbia

• Florida

• Georgia

• Hawaii

• Idaho

• Illinois

• Indiana

• Iowa

• Kansas

• Kentucky

• Louisiana

• Maine

• Maryland

• Massachusetts

• Michigan

• Minnesota

• Mississippi

• Missouri

• Montana

• Nebraska

• Nevada

• New Hampshire

• New Jersey

• New Mexico

• New York

• North Carolina

• North Dakota

• Ohio

• Oklahoma

• Oregon

• Pennsylvania

• Rhode Island

• South Carolina

• South Dakota

• Tennessee

• Texas

• Utah

• Vermont

• Virginia

• Washington

• West Virginia

• Wisconsin

• Wyoming

• Iraq

• Afghanistan

• Kuwait

• Korea

• Belgium

• Germany

• Kosovo

• United Kingdom

• Other Europe

• North America

• Central or South America

• Japan

• Other [Specify: {FREE TEXT}]

[IF OTHER LOCATION] City, Post, or Camp: {FREE TEXT}

109 Medical facility or unit where this DoDSER was completed or supporting MTF.

[USAF] Air Force Command: {FREE TEXT}

[USA]

• Fox Army Health Center

• Lyster Army Community Hospital

• Bassett Army Community Hospital

• RW Bliss Army Health Center

• Evans Army Community Hospital

• Walter Reed Army Medical Center

• Eisenhower Army Medical Center

• Martin Army Community Hospital

• Winn Army Community Hospital

• Tripler Army Medical Center

• Irwin Army Community Hospital

• Munson Army Health Center

• Blanchfield Army Community Hospital

• Ireland Army Community Hospital

• Bayne-Jones Army Community Hospital

• Kimbrough Ambulatory Care Center

• General Leonard Wood Army Community Hospital

• Patterson Army Health Center

• Keller Army Community Hospital

• Womack Army Medical Center

• Reynolds Army Community Hospital

• Moncrief Army Community Hospital

• William Beaumont Army Medical Center

• Brooke Army Medical Center

• Darnall Army Medical Center

• McDonald Army Health Center

• Kenner Army Health Center

• DeWitt Army Community Hospital

• Madigan Army Medical Center

• Weed Army Community Hospital

• Monterey Army Health Center

• DiLorenzo Tricare Health Clinic

• Lawrence Joel Army Health Center

• Kirk Army Health Center

• Barquist Army Health Center

• Guthrie Army Health Center

• Dunham Army Health Center

• Andrew Rader Army Health Center

• US Army MEDDAC Heidelberg

• Landstuhl Regional Medical Center

• US Army MEDDAC Bavaria

• US Army MEDDAC Camp Zama, Japan

• 121st General Hospital, Korea

• Rodriguez Army Health Center, Puerto Rico

• Iraq

• Kuwait

• Afghanistan

• Other [Specify: {FREE TEXT}]

[USMC & USN] Navy/Marine Corps location: {FREE TEXT}

110 Behavioral health provider

Name: {FREE TEXT}

Rank/grade:

• Contractor

• E1

• E2

• E3

• E4

• E5

• E6

• E7

• E8

• E9

• W1

• W2

• W3

• W4

• W5

• O1

• O2

• O3

• O4

• O5

• O6

• GS5

• GS6

• GS7

• GS8

• GS9

• GS10

• GS11

• GS12

• GS13

• GS14

• GS15

• Other DoD

• Other Non-DoD

Phone number: ({0-9}{0-9}{0-9}){0-9}{0-9}{0-9}-{0-9}{0-9}{0-9}{0-9}

DSN prefix: {FREE TEXT}

E-mail: {FREE TEXT}

Specialty:

• Licensed mental health counselor or equivalent

• Psychiatric nurse

• Psychiatrist

• Psychologist

• Social worker

• Other

111 Form completer

• Check if same as behavioral health provider

Name: {FREE TEXT}

Rank/Grade:

• Contractor

• E1

• E2

• E3

• E4

• E5

• E6

• E7

• E8

• E9

• W1

• W2

• W3

• W4

• W5

• O1

• O2

• O3

• O4

• O5

• O6

• GS5

• GS6

• GS7

• GS8

• GS9

• GS10

• GS11

• GS12

• GS13

• GS14

• GS15

• Other DoD

• Other Non-DoD

Command: {FREE TEXT}

Phone number: ({0-9}{0-9}{0-9}){0-9}{0-9}{0-9}-{0-9}{0-9}{0-9}{0-9}

DSN prefix: {FREE TEXT]

E-mail: {FREE TEXT}

112 Information based on certain types of records requires special privacy protection by some services’ suicide surveillance programs. Please indicate what sources of information were used to compile this report.

• The patient (non-fatalities)

• Coworkers/supervisors

• Responsible investigative agency officer

• Involved professionals, such as physicians, behavioral health clinicians, drug and alcohol counselors, chaplains, military police, family service personnel, etc.

• Family members

Review of records including:

• ER medical and behavioral health records

• Outpatient medical and behavioral health records

• Inpatient medical and behavioral health records

• Family advocacy records

• Army substance abuse program records

• Personnel records

• Responsible investigative agency records

• Courts-marital records

• Records related to the manner of death, such as casualty reports, toxicology/lab reports, pathology/autopsy reports, and suicide notes.

• Inspector general investigation

113 Comments: {FREE TEXT}

DoDSER 2014 Item Master 5 September 2014 Page 112 of 112