85 (85)    MH REPORT (601.93)

Name Value
REPORT NUMBER 85
INSTRUMENT SBR II DRAFT
RPT
.|   .|   Suicide Behavior Report|   |   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.>|   |   Self-Directed Violence (SDV) Classification System:|   <.DLL_String.>|   |   Questions and Answers|  |   1. Is 
there any indication that the person engaged in self-directed violent behavior, either preparatory or potentially harmful?|       <*Answer_5984*>|   2. Is there any indication that the person had 
self-directed violence related thoughts?|       <*Answer_5985*>|   2A. Were/Are the thoughts suicidal?|       <*Answer_5986*>|   3. Did the behavior involve any injury?|       <*Answer_5987*>|   3A. 
Was the injury fatal?|       <*Answer_5988*>|   3B. Was the behavior preparatory only?|       <*Answer_5989*>|   3C. Was the behavior interrupted by self or other(s)?|       <*Answer_5990*>|   4. Is 
there evidence of Suicidal Intent?|       <*Answer_5991*>|   |   |   Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic 
purposes.  Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.|      $~