| 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.| $~
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