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LOSS Activity Report
Activity Report
Activity Report
To be filled out by team members ASAP upon leaving the scene.
Deceased Info
Name of Deceased
*
Date of Response
*
Date of Death
*
Age of Deceased
*
Ethnicity
*
Marital Status
*
Married
Divorced
Single
Widow/Widower
Other
Marital Status
Team Information
Team Member completing this form
*
Team Members Involved
*
Name of Coroner's Investigator on Scene
Name of Law Enforcement at Scene and/or Name of Police Department (Detectives Only)
Scene Information
Activity
*
Outreach to survivors at a scene of a suicide
Delayed response outreach to survivors (not at a scene)
Death Notification
choose one
Time Activated
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
01
02
03
04
05
06
07
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45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Time Arrived at Scene
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
01
02
03
04
05
06
07
08
09
10
11
12
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41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Time Left Scene
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
01
02
03
04
05
06
07
08
09
10
11
12
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15
16
17
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21
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25
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27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Number of People on Scene
*
Number of People Served by LOSS
*
Did they want survivor information?
*
Yes
No
Donatos Cards Given
*
Quantity
Survivors names, relationships to the deceased, and contact information (phone, address, email)
Additional relevant information/comments about the scene
Submit
If you are human, leave this field blank.
