Student Risk of Suicide or Self-Harm Documentation

Suicide Risk Assessment Steps and Procedure

*Asterisk denotes drop-down list

Staff Member Completing Form:

Identification of Risk

Reason for Concern:

Risk Screening

Screening Conducted by:

Date of Screening:

Type of Screening Conducted: *

Results of Screening:

Recommendation:

asQ Suicide Risk Screen Guide and Tool

Notification of Parent/Guardian
Parent/Guardian:	Phone Number:
Parent/Guardian:	Phone Number:
Staff who notified parent/guardian:		Date Notified:
Name of parent/guardian notified:
Parent/Guardian Response: *
Steps Taken if Unable to Notify Parent:

Other Notifications (Dependent Upon Severity)
	Name:	Date:
☐ Building Administrator
☐ School Counselor
☐ Other (i.e. School Psych/Case Manager/Crisis Line):
☐ 911

Actions Taken/Resources Given

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Revised: October 17, 2023 Cross Reference: Procedure 2145P and Policy 2145