Act 101 of 2022 Notification Form

Act 101 of 2022 Notification Form

Suicide and Overdose Death Review Teams
Act 101 of 2022 authorizes the establishment of county suicide and overdose death review teams. A county, or two or more counties, may establish a suicide death review team, an overdose death review team, or both, for the purposes of collecting and examining suicide or overdose fatality information. For additional information about Act 101 of 2022, please visit our website.

Please complete the following form to comply with requirement of Act 101 of 2022 to notify the PA Department of Health of the establishment of a Death Review Team.
Name of person completing this form*

First NameLast Name
Email of person completing this form*
example@example.com
What type of Death Review Committee are you reporting to PA DOH?*

Overdose Review CommitteeSuicide Review CommitteeOverdose AND Suicide Review Committee
What is the jurisdiction of the Death Review Committee?*

CountyMulti-county
What county is represented by the Death Review Committee?*
Have the participating counties executed a memorandum of understanding?*

YesNo
What counties are represented by the Death Review Committee? (check all that apply)*

AdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYork
Is the lead organization of your Death Review Committee a Health Department?*

YesNo
Do you have county commissioner approval for the lead organization?*

YesNo
Lead Organization Name*
Death Review Committee primary contact*

First NameLast Name
Death Review Committee primary contact*
example@example.com
Secondary contact*

First NameLast Name
Secondary contact*
example@example.com
Records and information maintained by and shared with a death review team are subject to confidentially as required by Act 101 of 2022. 71 P.S. § 557.6. Record and information provided cannot be disclosed under the Right-to-Know Law and are not subject to discovery, subpoena, or introduction into evidence in a criminal or civil proceeding.
I hereby attest that I have read and understand this provision of Act 101 of 2022.*

Clear
I hereby attest that the information provided in this form is complete and accurate. *

Clear
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