National Law Enforcement Suicide Mortality Database Submission Form

Decedent Name:*

First NameLast Name

Date of Death:*

Date

Gender:*

MaleFemale

Race:

Employing Agency at time of Death:*

(Employing Agency & State)

Was the individual:

Individual was:

Marital Status:

Was the Decedent a veteran of the United States Military?*

YesNoUnknown

Branch of Service:

Did the Decedent have any deployments?*

YesNoUnknown

Manner of Death:

If a firearm was used, was it the decedent's duty weapon?*

YesNoUnknown

Was a note left?*

YesNoUnknown

If you would be willing to do a confidential interview with a case investigator, please provide contact information at (admin@nlesmd.com)

DISCLAIMER: The information collected through the submission form will be used in a If you would be willing to do a confidential interview with a case investigator, please provide confidential database with restricted access and no personally identifying information will be shared. The data collected will be used for research purposes in hopes to reduce the number of suicides among our first responder populations.