.|.|Suicide Behavior Event ||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||||1. Date of suicide event:| <*Answer_5361*>|2. Time of suicide event:| <*Answer_5362*>|3. Accuracy of Date and Time of
suicide event:| <*Answer_5363*>|4. Location of suicide event:| <*Answer_5364*>|5. Patient status at time of suicide event?| <*Answer_5365*>|5a. Inpatient Unit:| <*Answer_5368*>|5b.
Inpatient status at time of suicide event:| <*Answer_5369*>|6. Outcome of suicide event?| <*Answer_5366*>|6a. Hospital:| <*Answer_5367*>|7. Primary source of information:|
<*Answer_5370*>|7a. Name and phone number| <*Answer_5371*>|8. Type of contact with primary source:| <*Answer_5372*>|9. Patient stated their intention to commit suicide was: (Ask: What did you
think the outcome would be?)| <*Answer_5373*>|10. Staff evaluation of patient's intention to commit suicide:| <*Answer_5374*>|11. Staff evaluation of the lethality of patient's plan to commit
suicide:| <*Answer_5375*>|12. Does the patient have access to firearms?| <*Answer_5376*>|13. Description of suicide event:| <*Answer_5377*>|14. Patient is currently receiving treatment in
these areas (check all that apply):| <*Answer_5378*>|14a. Specialty Care:| <*Answer_5379*>|15. Primary care provider:| <*Answer_5381*>|16. Case manager / therapist:| <*Answer_5382*>|17.
Provider prescribing psychiatric medication:| <*Answer_5383*>|18. Brief plan and / or disposition (check all that apply):| <*Answer_5384*>|18a. Other:| <*Answer_5385*>| $~
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