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Run: Student Suicide Risk Screening and Safety Plan Documentation Form

Document a student suicide risk screening, parent or guardian notification, immediate protective actions, and follow-up safety planning in one place. Use it ...

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Submission Notice and Privacy Disclosure

Purpose of this submission

I understand this form may contain sensitive PII and protected student information. (required)

Yes No N/A

I understand the information will be used only for student safety, care coordination, required notifications, and the audit trail. (required)

Yes No N/A

Student and Case Identification

Student name (required)

Student ID

Grade level (required)

Date concern was identified (required)

Time concern was identified

Reported by (required)

Initial Concern and Screening Trigger

Primary concern type (required)

Brief description of the concern (required)

Describe only observable facts, direct quotes if relevant, and the minimum necessary context.

What triggered the screening now? (required)

Summarize the event, statement, or report that required immediate screening.

Suicide Risk Screening

Was a suicide risk screening completed? (required)

Screening tool or protocol used

Current suicidal thoughts reported?

Plan or intent indicated?

Access to means or lethal items indicated?

Overall risk level (required)

Risk rationale (required)

Document the observable factors and screening findings that support the selected risk level.

Immediate Protective Actions

Student supervision status (required)

Was the student removed from class or activity? (required)

Means restriction or safety steps taken

Immediate actions notes (required)

Record the actions taken, by whom, and the time sequence.

Parent or Guardian Notification

Was a parent or guardian notified? (required)

Date and time of notification

Notification method

Notification outcome

Safety Plan and Follow-Up

Was a safety plan created? (required)

Student coping strategies identified

Support contacts and escalation steps

List the adults, offices, or crisis resources the student should contact and the order of escalation.

Follow-up date

Follow-up owner

Documentation, Audit Trail, and Sign-Off

Additional notes

Submitted by (required)

Submitted by role (required)

Submission date and time (required)

Reviewed by

Review status

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